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THE 



PRACTICE OF MEDICINE. 



BY 



HORATIO C. WOOD, A.M., M.D., LL.D. (Yale), 

PROFESSOR OF THERAPEUTICS AND CLINICAL PROFESSOR OF NERVOUS DISEASES IN THE UNIVERSITY 
OF PENNSYLVANIA; MEMBER OF THE NATIONAL ACADEMY OF SCIENCE, 



AN] 




REGINALD H. FITZ, A.M., M.D. ; 



JERSEY PROFESSOR OF THE THEORY AND PRACTICE OF PHYSIC IN HARVARD UNIVERSITY ; VISITING 
PHYSICIAN TO THE MASSACHUSETTS GENERAL HOSPITAL; FORMERLY SHATTUCK 
PROFESSOR OF PATHOLOGICAL ANATOMY IN HARVARD UNIVERSITY. 




PHILADELPHIA: 

J. B. LIPPINCOTT COMPANY. 

LONDON: 10 HENRIETTA STREET, COVENT GARDEN. 
1 8 9 7. 



CONTENTS. 



SECTION I. 
GENERAL DISEASES. 



CHAPTEE I. 

DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS. 

PAGE 

General Considerations — Simple Anaemia — Chlorosis — Pernicious Anaemia — Leu- 
kocytosis — Leukaemia — Chloroma — Pseudo-Leukaemia — Myeloma — Hemor- 
rhagic Diathesis — Haemophilia — Scurvy — Purpura — Rheumatic Purpura — 
Henoch's Purpura — Purpura Haemorrhagica — Haemoglobinaemia — Diseases of 
the Spleen — Movable Spleen — Splenoptosis— Embolism and Abscess of the 
Spleen — Diseases of the Thyroid Gland — Goitre, Bronchocele, Struma — Ex- 
ophthalmic Goitre — Myxcedema — Tumors of the Thyroid— Diseases of the 
Thymus Gland— Tumors of the Thymus Gland — Diseases of the Adrenal 
Glands — Addison's Disease 1 



CHAPTEE II. 

LOCOMOTOR AND CONSTITUTIONAL DISEASES. 

Myositis— Acute Polymyositis — Primary Myopathy — Pseudo-Hypertrophic My- 
opathy — Atrophic Myopathy — Thomsen's Disease — Rickets — Hemorrhagic 
Rickets — Osteomalacia — Obesity — Acute Articular Rheumatism — Gonorrhceal 
Rheumatism — Chronic Articular Rheumatism — Arthritis Deformans — Muscu- 
lar Rheumatism — Gout — Lithaemia— Diabetes Mellitus— Diabetes Insipidus . . 44 



CHAPTEE III. 

INFECTIOUS DISEASES. 

Scarlet Fever — Measles— German Measles — Chicken-Pox — Small-Pox — Cow-Pox 
— Miliary Fever — Typhoid Fever — Typhus Fever — Relapsing Fever — Infectious 
Jaundice — Cerebro-Spinal Meningitis — Influenza — Dengue —Plague — Diph- 
theria — Whooping-Cough — Mumps — Erysipelas — Septicaemia — Pyaemia — Tet- 
anus — Malarial Diseases — Dysentery — Cholera — Cholera Nostras — Yellow 
Fever — Actinomycosis — Mycetoma — Rabies — Anthrax — Foot-and-Mouth Dis- 
ease — Glanders — Tuberculosis, General and Local — Lupus — Scrofula — Leprosy 

—Syphilis 95 

v 



vi 



CONTENTS. 



CHAPTER IV. 

DISEASES DUE TO ANIMAL PARASITES. 

PAGE 

Protozoa — Amoeba coli— Sporozoa — Hsematozoon malarige— Coccidium oviforme 
— Psorosperms — Infusoria — Megastoma entericum — Cercomonas — Trichomonas 
— Balantidium coli — Helminthiasis — Taeniae, Tape-worms — Taenia solium — 
Taenia saginata — Bothriocephalus latus — Cysticercus cellulosse — Echinococcus 
— Trematodes — Flukes — Distoma haematobium — Distoma pulmonale — Distoma 
hepaticum — Anellides, Leeches — Nematodes, Sound and Thread Worms — 
Ascaris lumbricoides — Oxyuris vermicularis — Eustrongylus gigas — Strongylus 
longivaginatus — Ankylostoma duodenale — Tricocephalus dispar — Filaria medi- 
nensis — Filaria sanguinis hominis — Hsematochyluria, Lymph-Scrotum — Tri- 
china spiralis— Arthropodes — Pentastoma denticulatum— Sarcoptes hominis — 
Parasitic Insects — Pediculus capitis, vestimentorum, pubis— Cimex lectularius 
— Pulex irritans — Sarcopsylla penetrans — Myiasis, Maggots 321 



CHAPTER V. 

POISONING. 

Acute Poisoning. 

Narcotics : Opium, Alcohol, Chloral, Chloroform and Ether, Illuminating Gas, 
Prussic Acid, Mtrobenzol, Carbolic Acid, Oil of Tansy, Santonin, Belladonna, 
Hyoscyamus, Datura, Jamestown (" Jimson") Weed, Cannabis Indica, Hyos- 
cine, and Cocaine. — Convulsants : Strychnine, Cocaine. — Paralyzants : Chloral, 
Calabar Bean, the Nitrites, Gelsemium, Lobelia, Coniine, Woorari, Pelletier- 
ine. — Cardiants : Digitalis, Veratrum Viride, Aconite, the Nitrites, Antimony. 
— Irritants : Mineral Acids and Vegetable Acids, Oxalic Acid, Cantharides, 
Irritant Oils, Savine, Phosphorus 350 

Chronic Poisoning. 

Lead, Arsenic, Antimony, Alcohol, Delirium Tremens, Opium, Cocaine 362 



SECTION II. 

DISEASES OF THE NERVOUS SYSTEM. 

CHAPTER I. 

GENERAL SYMPTOMATOLOGY. 

Disturbances of Motion— Disturbances of Coordination — Disturbances of Sensa- 
tion— Vaso-Motor and Trophic Disturbances— Disturbances of Intellection . . 377 



CHAPTER II. 

FUNCTIONAL NERVOUS DISEASES. 

Insanity— General Considerations— Constitutional Insanities— Pure Insanities- 
Melancholia — Mania — Confusional Insanity — Terminal Dementia — N euro- 
pathic Insanities — Paranoia — Periodical Insanity — Neurasthenia — Hysteria — 
Astasia Abasia— Singultus— Vertigo— Epilepsy— Periodic Paralysis— Laryngis- 
mus Stridulus— Convulsions — Local Spasms— St, Vitus' s Dance — Reflex Chorea 



CONTENTS. 



vii 



— Chorea of Pregnancy — Convulsive Choreas— Automatic Chorea— Hereditary- 
Chorea — Tetany — Paramyoclonus Multiplex — Paralysis Agitans — Traumatic 
Neurosis — Caisson Disease— Heat Exhaustion — Thermic Fever — Occupation 
Neuroses— Headaches— Migraine — Sleep, its Disorders and Accidents — Corre- 
lated Disorders of Memory and Consciousness — Neuralgia 389 

CHAPTER III. 

ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 

Cerebral Localization — Motion — Sensation — Athetosis — Aphasia — Cerebellar Lo- 
calization — Diseases of the Membranes of the Brain — Pachymeningitis — Lepto- 
meningitis — Acute Meningitis— Tubercular Meningitis — Chronic Meningitis — 
Disorders of the Cerebral Circulation — Cerebral Anaemia — Cerebral Hyper- 
emia — Diseases of the Blood-Vessels of the Brain— Cerebral Thrombosis 
and Embolism — Cerebral Aneurisms — Thrombosis of Cerebral Sinuses— Cere- 
bral Hemorrhage— Cerebral Palsy of Children— Diseases of the Brain— Acute 
Hemorrhagic Encephalitis— Suppurative Encephalitis — Hydrocephalus— Acute 
Periencephalitis— Chronic Periencephalitis — Disseminated Sclerosis — Intra- 



cranial Tumors — Cerebral Syphilis 471 

CHAPTEE IV. 

DISEASES OF THE MEDULLA OBLONGATA. 
General Considerations — Glosso-Labial Paralysis 536 

CHAPTER V. 



ORGANIC DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 

Spinal Localization — Spinal Hemorrhage — Spinal Embolism and Thrombosis — 
Spinal Anaemia — Plyperaemia of the Spinal Cord — Acute Spinal Meningitis — 
Chronic Spinal Meningitis — Spinal Abscess — Spinal Tumor — Acute Ascending 
Paralysis — Acute Myelitis — Chronic Myelitis — Compression Myelitis— Acute 
Poliomyelitis — Chronic Poliomyelitis — Syringomyelia — Locomotor Ataxia — 
Antero-Lateral Sclerosis — Combined Sclerosis — Friedreich's Ataxia — Syphilis 
of the Spinal Cord and its Membranes ... 540 

CHAPTER VI. 

ORGANIC DISEASES OF THE NERVES. 

Local Paralyses of Motion — Neuritis — Simple Neuritis — Parenchymatous Neuri- 
tis— Mesoneuritis — Multiple Neuritis— Sciatica — Inflammation of the Facial 
Nerve— Inflammation of the Trigeminal Nerve — Neuritic Muscular Atrophy — 
Neuroma — Syphilis of the Nerve 594 

CHAPTER VII. 

VASO MOTOR AND TROPHIC DISEASES. 



Raynaud's Disease — Perforating Ulcer — Angioneurotic (Edema — Scleroderma — 
Morphoea — Facial Hemiatrophy — Xeroderma pigmentosum — Sclerema neona- 
torum — (Edema neonatorum — Acromegaly 619 



viii 



CONTENTS. 



SECTION III. 

DISEASES OF THE CIRCULATORY APPARATUS. 

CHAPTEE I. 

DISEASES OF THE PERICARDIUM. 

PAGE 

Pneum opericardium — Hy dropericardium — Hsemopericardium — Acute Pericar- 
ditis — Chronic Pericarditis 628 

CHAPTER II. 

DISEASES OF THE HEART AND MYOCARDIUM. 

Malformation — Hypertrophy — Dilatation — Fatty Infiltration — Fatty Degenera- 
tion — Acute Myocarditis — Chronic Myocarditis — Thrombosis— Cardiac Aneu- 
rism — Rupture — Tumors 637 

CHAPTEE III. 

DISEASES OF THE ENDOCARDIUM. 

Acute Endocarditis— Chronic Endocarditis— Chronic Valvular Diseases — Mitral 
Insufficiency — Mitral Stenosis — Aortic Insufficiency — Aortic Stenosis — Tri- 
cuspid Insufficiency — Tricuspid Stenosis — Pulmonary Insufficiency — Pul- 
monary Stenosis — Treatment of Chronic Heart Disease — Cardiac Neuroses — 
Palpitation — Irregularity — Tachycardia— Bradycardia — Arhythmia — Angina 
Pectoris 651 

CHAPTEE IV. 

DISEASES OF THE ARTERIES. 
Arterio-Sclerosis — Aneurism 686 



SECTION IV. 

DISEASES OF THE RESPIRATORY APPARATUS. 

CHAPTEE I. 

DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 

Diseases of the Nose — Epistasis — Phinitis — Autumnal Catarrh — Diseases of 
the Larynx — Laryngitis— True and False Croup — Tumors — Spasm — Diseases 
of the Trachea and Bronchi — Trachitis — Acute Bronchitis— Chronic Bron- 
chitis — Membranous Bronchitis — Bronchiectasis — Bronchial Obstruction — 
Asthma 700 

CHAPTEE II. 

DISEASES OF THE LUNGS. 

Congestion — Haemoptysis — Thrombosis and Embolism — (Edema — Atelectasis — 
Emphysema— Acute Pneumonia — Chronic Fibrous Pneumonia — Broncho- 
Pneumonia — Gangrene — Abscess — Tumors— Cancer 730 



CONTENTS. 



ix 



CHAPTER III. 

DISEASES OF THE PLEURA AND OF THE MEDIASTINUM. 

PAGE 

Diseases of the Pleura — Pneumothorax — Hydrothorax — Hemothorax — Acute 
Pleurisy — Chronic Pleurisy — Empyema — Tumors — Diseases of the Mediasti- 
num — Mediastinitis — Tumors 770 



SECTION V. 

DISEASES OF THE DIGESTIVE APPARATUS AND 
OF THE PERITONEUM. 

CHAPTER I. 

DISEASES OF THE MOUTH, PHARYNX, AND CESOPHAGUS. 

Diseases of the Mouth, Tongue, and Salivary Glands — Stomatitis — Glossitis — 
Psoriasis of the Tongue— Eanula — Parotitis — Diseases of the Pharynx and 
Tonsils — Acute Pharyngitis — Chronic Pharyngitis — Angina Ludovici — Retro- 
pharyngeal Abscess — Acute Tonsillitis— Chronic Tonsillitis— Diseases of the 
(Esophagus — Malformation — Stenosis — Dilatation — Diverticula — Perforation 
— Rupture — Oesophagitis — Tumors— Cancer— Spasm — Paralysis 791 



CHAPTER II. 

DISEASES OF THE STOMACH. 

Methods of Examination — Gastroptosis — Dilatation — Perforation — Rupture — 
Hemorrhage — Acute Gastritis — Pseudo-membranous Gastritis — Phlegmonous 
Gastritis — Chronic Gastritis — Ulcer — Tumors — Cancer — Neuroses — Nervous 
Dyspepsia 817 



CHAPTER III. 

DISEASES OF THE INTESTINE. 

Enteroptosis — Hemorrhage — Acute Enteritis — Chronic Catarrhal Enteritis — 
Pseudo-membranous Enteritis — Ulcerative Enteritis — Diphtheritic Enteritis — 
Phlegmonous Enteritis — Appendicitis — Intestinal Obstruction — Intussuscep- 
tion — Cancer — Constipation — Typhlitis — Colitis — Proctitis — Ulcer — Tumors — 
Neuroses 855 



CHAPTER IV. 

DISEASES OF THE LIVER, GALL-BLADDER, AND BILE-DUCTS. 

Diseases of the Liver— Malformation — Malposition — Fatty Infiltration — Con- 
gestion — Perihepatitis, Acute and Chronic — Subphrenic Abscess — Acute Yel- 
low Atrophy — Acute Suppurative Hepatitis — Abscess of the Liver — Chronic 
Fibrous Hepatitis — Hypertrophic Cirrhosis — Amyloid Degeneration — Cancer- 
Tumors — Diseases of the Gall-Bladder and Bile-Ducts — Jaundice — Cholan- 
gitis — Cholecystitis — Cholelithiasis — Tumors— Cancer 909 



X 



CONTENTS. 



CHAPTEE V. 

DISEASES OF THE PANCREAS AND OF THE PERITONEUM. 

PAGE 

Diseases of the Pancreas — Hemorrhage — Acute Pancreatitis — Chronic Pancrea- 
titis — Calculi — Cysts — Cancer — Tumors — Diseases of the Peritoneum — Hemor- 
rhage — Ascites — Acute Peritonitis — Chronic Peritonitis — Chronic Serous Peri- 
tonitis—Cancer — Tumors 950 



SECTION VI. 

DISEASES OF THE URINARY APPARATUS. 

CHAPTEE I. 

DISEASES OF THE KIDNEYS. 

Anomalies of Shape and Position — Fused Kidney — Movable Kidney — Disorders 
of Secretion — Hematuria — Hemoglobinuria — Urobilinuria — Indicanuria — 
Melanuria — Alkaptonuria, Brenzkatechinuria, Hydrochinonuria — Chyluria, 
Lipuria — Albuminuria, Globulinuria, Nucleoalbuminuria (Mucinuria), Albu- 
mosuria, Peptonuria — Fibrinuria — Lithuria, Uraturia, Uricaciduria — Oxaluria 
— Phosphaturia — Cystinuria — Glycosuria, Melituria — Acetonuria, Diaceticacid- 
uria — Lipaciduria — Hydrothionuria — Casts — Pyuria — Uraemia — Dropsy — 
Congestion — Thrombosis and Embolism — Acute Nephritis — Chronic Nephritis 
— Chronic Diffuse Nephritis — Chronic Fibrous Nephritis — Amyloid Degener- 
ation — Suppurative Nephritis, Abscess of the Kidney 989 



CHAPTEE II. 



CYSTS AND TUMORS OF THE KIDNEY AND DISEASES OF THE RENAL 
PELVIS AND THE BLADDER. 

Eenal Cysts— Multilocular Cystic Kidney— Tumors— Pyelitis, Pyelonephritis — 
Hydronephrosis, Pyonephrosis — Suppurative Paranephritis — Nephrolithiasis 
— Renal Colic — Diseases of the Bladder — Enuresis, Incontinence of Urine — 
Neuralgia of the Bladder, Irritable Bladder— Cystitis 1041 



formulary 

Charts of Temperature 



1063 



1067 



THE PRACTICE OF MEDICINE. 



SECTION I. 

GENERAL DISEASES. 



CHAPTER I. 

DISEASES OF THE BLOOD AND OF THE DUCTLESS GLANDS. 
GENERAL CONSIDERATIONS. 

Although the composition of the blood is variously altered in many 
diseases, yet there are only certain conditions in which the constancy of 
the changes and their importance in the production of symptoms are 
such as to be sufficiently characteristic. Especial attention is, therefore, 
to be paid to variations in the quality and quantity of the blood- corpus- 
cles and to the amount of haemoglobin present. The total number of red 
and of white blood- corpuscles is to be estimated and their proportion 
determined. The morphological characteristics of the red and white 
corpuscles are to be ascertained, and the latter are to be classified in 
accordance with intrinsic differences which are to be observed by especial 
methods of preparation, and the ratio of such differentiated leukocytes 
to each other is to be calculated. Furthermore, the percentage of haemo- 
globin is to be ascertained. Herz calls attention to the possibility of a 
further inquiry into the specific gravity of the red blood-corpuscles and 
of the plasma, by means of which additional modifications in the char- 
acteristics of the red blood- corpuscles may be determined. 

For practical purposes the examination of the blood is limited to the 
recognition of the number of red and white blood- corpuscles present in 
the cubic millimetre and the percentage of haemoglobin. The blood-cor- 
puscles are to be counted by means of the Thoma-Zeiss or Gowers counting 
apparatus, or by the haematokrit, as advocated by Daland. Normal blood 
contains about five million red corpuscles and six thousand white cor- 
puscles in the cubic millimetre. Variations in the result of the calcula- 
tion of the total number of red corpuscles to the extent of two hundred 
) l 



2 



GENERAL DISEASES. 



thousand in a cubic millimetre and of the white corpuscles to the extent 
of one thousand are possible even to accurate observers, and are, there- 
fore, of no practical significance. Daland asserts that less time, skill, 
and fatigue are necessary if the haematokrit is employed. Its use is 
objected to as requiring more blood, a cut in the thumb, and a bulky 
instrument. Fleischer s apparatus is most frequently used for the de- 
termination of the percentage of haemoglobin, although the value of such 
estimates is merely relative. 

In the examination of the red blood- corpuscles attention is to be paid 
to variations in size and shape, and a distinction is to be drawn between 
corpuscles of normal size and those which are large, — macrocytes, — or 
small, — microcytes, — or irregularly shaped, — poikilocytes. Nucleated 
red blood- corpuscles — normoblasts — may be found in small numbers in 
normal blood, but are increased in anaemia, while large nucleated red 
blood- corpuscles — macro-, megalo-, or giganto-blasts— are found to any 
considerable extent only in pernicious anaemia. Poikilocytosis occurs in 
a variety of diseases in which there are serious disturbances of nutrition. 
The white blood-corpuscles, — leukocytes, — according to peculiarities 
made evident by staining, especially by the Ehrlich-Biondi method, are 
divided into lymphocytes, mononuclear, transitional, and polynuclear 
leukocytes, and eosinophiles or eosinophilous leukocytes. They occur 
in normal blood in the following proportions : 

Lymphocytes, twenty to thirty per cent. 

Polynuclear leukocytes, sixty to eighty per cent. 

Mononuclear and transitional leukocytes, six per cent. 

Eosinophiles, two to four per cent. 

A considerable deficiency of red blood-corpuscles produces a series of 
symptoms due essentially to a diminution in the quantity of haemoglobin 
in the blood. Like symptoms occur when the quantity of haemoglobin is 
diminished, although the total number of red blood- corpuscles may be 
normal. A distinction is thus drawn between anaemias, in which the total 
number of red blood- corpuscles is diminished, and chlorosis, in which the 
percentage of haemoglobin is diminished, although the, total number of 
red blood-corpuscles may be relatively normal. Such a distinction is not 
absolute, since in the severer varieties of chlorosis the number of red 
blood- corpuscles is usually diminished. 

A diminution in the total number of red blood- corpuscles occurs 
under a variety of conditions, some of which are readily apparent, as a 
visible hemorrhage ; others are obscure or unknown : hence a distinction 
is drawn between anaemia or simple anaemia, chlorosis, and pernicious 
anaemia. 

ANAEMIA OR SIMPLE ANEMIA. 

Simple anaemia is usually secondary to some obvious cause, as hemor- 
rhage, serious disturbance of nutrition (whether from disease, insufficient 
or improper food, unwholesome occupation, or faulty hygienic surround- 



DISEASES OF THE BLOOD. 



3 



ings), or from the action of poisons, as lead, mercury, and arsenic. Eesi- 
dence in the tropics often produces a pallor of the skin called tropical 
anaemia, but Glogner and others find in such cases that the red blood- 
corpuscles and haemoglobin are not diminished. The above-mentioned 
causes of anaemia are especially active, according to Weiss and Monti, 
when affecting young children. 

Symptoms. — In all varieties of anaemia there are certain symptoms 
in common, although varying in severity and in rapidity of development. 
They are dependent partly upon a deficiency of haemoglobin, partly upon 
unknown modifications in the composition of the blood. Such symptoms 
are mild or severe, may begin as the former and end as the latter, or may 
be severe from the outset. Shortness of breath and palpitation are in- 
dicative of disturbance in oxygenation. Headache, backache, neuralgia, 
dizziness, obscured vision, ringing in the ears, fainting, mental and bodily 
weakness, are the effects of anaemia upon the nervous system. Loss of 
appetite, epigastric discomfort after eating, belching, flatulence, and con- 
stipation are the evidences of an altered digestion. Disturbances of 
menstruation are frequent, the catamenia being irregular or suppressed, 
scanty or profuse, often painful and exhausting, and the discharge light- 
colored. The skin, lips, and tongue are pale. Emaciation may or may 
not be present. A systolic souffle is often to be heard both at the base and 
at the apex of the heart, there is accentuation of the pulmonic second 
sound, and a venous hum is usually present at the base of the neck. The 
pulse is rapid, compressible, and of diminished volume. The tempera- 
ture is frequently elevated, usually to a slight degree, and the course is 
often irregular. The urine may be pale or high-colored, but is generally 
of lowered specific gravity. The blood-count shows a deficiency of red 
blood- corpuscles and a proportionate diminution in the percentage of 
haemoglobin. 

Diagnosis. — Simple or secondary anaemia is to be recognized by the 
appreciation of an obvious cause for the deficiency of red blood-corpuscles 
and haemoglobin. 

Prognosis. — The prognosis is favorable when the cause can be re- 
moved, provided its action has not been excessively prolonged. 

Treatment. — The treatment of simple anaemia, after removal of the 
cause, consists in the administration of iron with strychnine and other 
bitter tonics to aid in digestion, with laxatives if constipation be pro- 
duced. 

It has been shown by the various chemists working under the control 
of Robert that the administration by the mouth of the ordinary prepa- 
rations of iron does not perceptibly affect the elimination of iron by the 
kidneys, although after the hypodermic injection of iron and sodium 
citrate (one milligramme for seven kilogrammes of weight) forty per 
cent, of the preparation can be obtained from the urine unaltered. It 
would seem, therefore, that the iron should be used hypodermically. It 



4 



GENERAL DISEASES. 



was found, however, that unless the dose is very small it produces great 
renal irritation : so that the quantity mentioned above should never be 
exceeded. Further, it has been proved by Moerner, Gottlieb, Carl 
Jacobi, and others that iron is eliminated through the intestinal tract 
very freely : so that the question whether it does or does not escape from 
the kidneys is of comparatively little importance. The theory of Bunge, 
that the value of iron in chlorosis is due to a peculiar chemical action 
in the alimentary tract, which causes the natural albuminous iron com- 
pounds in the food to be absorbed, is certainly unproved and improba- 
ble. The discovery by Busch that the administration of pure or impure 
haemoglobin distinctly increases the elimination of iron from the urine, 
in conjunction with results already quoted, and with judicious advertise- 
ment by interested pharmacists, has led to the large use of haemoglobin 
compounds or derivatives. 

The chemical work which has been done upon the absorption and 
elimination of iron is, however, at this time of no practical value. The 
fact that a certain preparation of iron yields a large percentage to the 
urine is no proof of its superiority. It is the iron which remains, and 
not that which escapes from the body, that does good ; and it may well 
be that a preparation which is absorbed easily and which escapes easily 
is of less value than one which is absorbed slowly and does not escape 
at all. Clinical experience is the only guide in this matter ; it is possi- 
ble that manganese may be of service in simple or chlorotic anaemia, and 
that the pepto-manganates of iron may have especial value ; but our ex- 
perience is that the older and simpler preparations will effect all that can 
be achieved by the more modern, complex, and expensive forms of iron. 
Among solid preparations fit for exhibition in pill may be mentioned, as 
being as free as may be from astringency, pilulae ferri carbonatis, pills 
of ferrous carbonate, Blaud's pill, dose one to two pills ; and ferrum re- 
ductum, reduced iron, dose two to five grains. For exhibition in solution 
we would recommend ferri et ammonii citras, iron and ammonium citrate, 
dose three to six grains ; also ferri et ammonii tartras, iron and ammonium 
tartrate, dose three to six grains. All the sulphates of iron are highly 
astringent. The tincture of the chloride is astringent, and very dele- 
terious to the teeth. 

CHLOROSIS. 

This variety of anaemia, sometimes called the green sickness, is so 
named from x^P^, "pale green,'' and is usually regarded as a primary 
disease of the blood. It is conventionally characterized by a marked 
deficiency of haemoglobin without a corresponding diminution in the 
number of red blood- corpuscles. 

Etiology. — Chlorosis usually occurs in females, especially among 
blondes, generally at or soon after the age of puberty, although Eieder 
reports typical cases occurring in persons between thirty and forty-two 
years of age. It is probable that a congenital predisposition to this 



DISEASES OF THE BLOOD. 



5 



affection may exist dependent upon debility or disease of the parents. 
Faulty hygienic surroundings, as bad air, unwholesome food, overwork, 
mental, moral, and physical strain or excesses, are important as exciting 
causes. Meinert has found gastroptosis in forty cases of chlorosis, and 
regards this condition as a cause of the disease, attributing its occurrence 
to the use of corsets during the developmental changes at puberty. The 
etiological importance of the development of the sexual function is 
generally recognized from the frequent occurrence of chlorosis at or 
about the age of puberty, and especially in those in whom irregularities 
exist in the development of this function. Sir Andrew Clark has sug- 
gested that the absorption in the colon of toxic products from retained 
faeces is important in the etiology, while Pick attributes a like effect to 
toxic absorption from the dilated stomach which he frequently finds in 
chlorosis. Yon Noorden, however, disputes the theory that chlorosis is 
due to the absorption of putrefactive products in the intestine. Enlarge- 
ment of the spleen, found by Jacobi in severe cases, has been observed by 
Chvostek and Clement in many cases, and the latter regards chlorosis as 
of infectious origin. 

Morbid Anatomy. — An anatomical basis for chlorosis was first ren- 
dered probable by the researches of Yirchow, who frequently found a 
hypoplasia of the arteries. This was especially characterized by a thin, 
narrow, and elastic aorta, with irregular origin of its primary branches, 
especially of the intercostal and lumbar arteries, and by a superficial, 
spotted, fatty degeneration of its intima. Hypoplasia of the heart, uterus, 
and ovaries is frequently associated, although in the adult secondary hy- 
pertrophy of the heart and hyperplasia of the uterus may be present. 

Symptoms. — The patient suffers from symptoms of a mild or severe 
anemia, chiefly attributable to the deficiency of haemoglobin. Head- 
ache, dizziness, fainting-fits, blurring of vision, and ringing in the ears 
often occur. Backache, neuralgia, hebetude, and muscular weakness 
may supervene, and hysterical paroxysms are frequent. Palpitation and 
dyspnoea on slight exertion or in consequence of emotional excitement 
are present. Slight elevations of temperature without apparent cause 
are not uncommon, and may continue for days or weeks. Digestive dis- 
turbances are conspicuous, and an abnormal appetite for pickles, slate- 
pencils, and chalk, an excessive fondness for sweets, a lack of appetite 
for nutritious foods, epigastric distress after meals, frequent eructations 
of gas, occasional vomiting, and persistent constipation are noticeable. 
Oswald and others find that an excess of free hydrochloric acid in the 
stomach is the rule, and this observer attributes the digestive disturbance 
to a lack of motor activity, a view which is favored by the noticeable 
occurrence in this disease of a displaced and dilated stomach. The secre- 
tion of urine is but little affected. It is usually pale, sometimes alkaline, 
its specific gravity about 1015, with a slight diminution in the elimina- 
tion of urea. Menstrual disturbances are frequent, especially amenor- 



6 



GENERAL DISEASES. 



rhoea, or a scanty flow, and dysmenorrhea. Displacements of the uterus 
and ovaries are common, and chlorotic women are usually early subjected 
to gynaecological treatment. The patients often appear well nourished, 
although puffiness of the eyelids and ankles may occur, especially after 
the symptoms have existed for some time. Pallor of the skin, mouth, 
and tongue is conspicuous. The occasional occurrence of a greenish or 
greenish-yellow tint has already been indicated, and flushing of the cheeks 
from emotional excitement is often of ready occurrence. The impulse 
of the heart, especially when rapid, is visible and palpable over an in- 
creased area, and a systolic souffle is frequently to be heard either over 
both base and apex or over one or more valves, especially the pulmo- 
nary valve, the second sound of which is usually accentuated. A carotid 
pulse is often visible, and a murmur is, as a rule, easily heard on auscul- 
tation of this artery. Auscultation of the internal jugular vein, espe- 
cially the right, at the base of the neck usually reveals the venous hum 
or bruit de diable, which, however, is to be heard in other than chlorotic 
individuals. The pulse varies in frequency in accordance with the degree 
of excitability of the patient, and is of moderate volume and diminished 
tension. 

The examination of the blood shows that the red blood- corpuscles are 
not especially modified in number, although during the course of the 
disease and especially in the severer types there may be oligocythemia to 
the extent of less than one-half the normal number of red corpuscles. 
They are often noticeably pale in color, vary considerably in size and 
shape, and the nucleated forms are relatively numerous. The percentage 
of haemoglobin may be reduced to thirty-five per cent, even when there 
is no considerable diminution in the number of red blood- corpuscles. 
It may be as low as twenty-five per cent, when there is a considerable 
reduction in the number of red corpuscles. The alkalinity of the blood 
is stated to be diminished. 

The symptoms of chlorosis are often prolonged over a period of 
months or years, in the latter case temporary improvement and repeated 
occurrences of the symptoms being frequent. Serious complications may 
arise, the most frequent of which is ulcer of the stomach, this affection 
being often found in young women who have previously suffered from 
chlorotic symptoms, especially from gastralgia. In fatal cases of chronic 
tuberculosis and chronic diffuse nephritis hypoplasia of the aorta is fre- 
quently found, and the suggestion is direct that such affections may pur- 
sue a more severe course when occurring in chlorotic patients. Dieulafoy 
and Hanot report cases of transitory nephritis in the course of chlorosis. 
Thrombosis of the peripheral veins and of the cerebral sinuses has oc- 
curred in the later stages of severe chlorosis, and may prove the imme- 
diate cause of death. 

Diagnosis. — Since chlorosis is a disease in which anaemia is a condi- 
tion, the diagnosis largely depends upon the time when the symptoms 



DISEASES OF THE BLOOD. 



7 



occur and upon the absence of causes of a secondary anaemia. The diag- 
nosis is to be confirmed by the examination of the blood, since most 
writers regard as essential an excessive diminution of the haemoglobin in 
the blood without a proportionate loss of red blood-corpuscles. In the 
advanced stages of chlorosis the number of red blood-corpuscles as well 
as the percentage of haemoglobin may be largely lowered, in which case 
a knowledge of the etiology and course of the symptoms is essential in 
order to make a correct diagnosis. Henry maintains that in one series 
of cases the number and size of the red blood-corpuscles may be normal 
while the haemoglobin is deficient, in a second series with a normal 
number of red corpuscles there may be a diminution of their size while 
the percentage of haemoglobin is normal, and in a third series with a 
diminution in the number of red blood- corpuscles there may be a dimin- 
ished or an increased quantity of haemoglobin. 

In cases of doubt chlorosis is to be differentiated from secondary 
anaemias by the etiology of the latter, and from pernicious anaemia by 
the progressive course of this disease, of which retinal hemorrhages and 
the examination of the blood furnish additional evidence. 

Prognosis. — Chlorosis is rarely fatal, and then usually from such 
complications as venous thrombosis or ulcer of the stomach. Recur- 
rent attacks are frequent, especially in the autumn and winter, and are 
sometimes induced by pregnancy, which condition may also relieve the 
symptoms. 

Treatment. — The treatment of a case of chlorosis must vary in many 
ways in accordance with the individual needs of the case. In the mild- 
est form of the affection it may be simply necessary to turn the patient 
out- doors in the country, to give nutritious, easily digested diet, and to 
administer iron and arsenic. On the other hand, in the severest case 
a strict rest-cure (see page 402) may be required. Between these ex- 
tremes every grade of case exists. Whenever it is practicable, the city 
girl should be sent to the country, put into warm but light clothing, and 
required to spend many hours a day in the open air, and the most of the 
remainder in bed. The exercise must be in proportion to the strength 
of the patient : any exertion which produces exhaustion or sleeplessness 
at night, or increased apathy or indifference to exertion the next day, is 
in all probability deleterious. Complete change of climate, from the 
mountains to the sea-shore, or from the sea-shore to the mountains, is 
often very serviceable. Better results are also obtained when the vaca- 
tion from the city is spent partly in the mountains and partly at the 
sea- shore. The diet must be varied according to the individual case : the 
fat chlorotic girl should use carbo-hydrates and fats in moderation ; the 
lean girl, on the other hand, should be given butter, cream, sweet oil, 
cod-liver oil, and similar substances to the point of gastric tolerance. 

Alcohol should never be given in excess, but the moderate use of red 
wine or of malt liquors at meals may be distinctly beneficial. If, how- 



8 



GEXEBAL DISEASES. 



ever, they produce flushing of the face, or disturb the stomach, they 
should be altogether withdrawn. 

Two medicines which are essential in the treatment of chlorosis are 
iron and arsenic, but other drugs are frequently beneficial. Thus, laxa- 
tives, preferably vegetable, should be used unless there is already a ten- 
dency to looseness of the bowels : bitter tonics and strychnine should be 
employed when, as is commonly the ase, there is failure of appetite, with 
inactivity of the digestive organs ; quinine in moderate doses is often use- 
ful, but in large doses may do harm. Active treatment of the amenorrhea 
is not often effective or judicious, the suppression of the menstruation 
being probably a secondary and not a primary phenomenon, which is 
remedied by the return of health. We have never had satisfaction in 
the use of apiol, potassium permanganate, or other lauded emmena- 
gogues ; the old-fashioned Dewees's emmenagogue mixture (see formula 
1) has in our hands given the greatest benefit of any remedy of the class. 
If at any time a menstrual flow appear, immediate absolute rest in bed 
should be enforced, with the use of the hot hip bath, an active aloetic or 
podophyllin purge, and the drinking of hot ginger or other tea. Except 
in rare cases, local treatment of the pelvic organs, other than the use of 
douches, is unjustifiable. 

In addition to what has been said as to the use of iron (see page 
4), it should be stated that in chlorosis the iron should be given in great 
excess, and that there is no sufficient reason for believing that dried 
haemoglobin peptonate or other organic complicated preparation of iron 
is superior to the older and simpler forms. It will often be found that 
one preparation of iron disturbs the stomach less than does another. 
These individual peculiarities can be judged of only by trial, but should 
be carefully attended to in every case. When iron produces digestive 
disturbance the preparation should be varied and the doses reduced until 
toleration is obtained. Arsenic is a valuable remedy, to be given in 
moderate doses with the iron : Fowler's solution, two drops after meals. 

In some cases of chlorosis hydrotherapeutic treatment is of value ; 
when there is not exhaustion, short sea-baths may be useful, care being 
taken not to produce exhaustion by struggles with breakers, or by the 
removal of the bodily heat through long immersion in cold sea- or other 
water. In weak cases quiet baths in warm sea- water are more efficacious. 
Very commonly the cold douche in the morning, followed by hard rub- 
bing with a towel, is of excellent service : usually the momentary hot 
douche followed by a momentary cold affusion is very effective. The 
cold pack, given once or even twice in the day, may be serviceable: 
the naked person should be enveloped in a sheet wrung out of ice-cold 
water, and then wrapped in blankets and allowed to stay perfectly quiet 
from fifteen minutes to one hour. In all cases in which cold water is 
used, if reaction be not complete harm rather than good will be done by 
continuing the remedy. 



DISEASES OF THE BLOOD. 



PERNICIOUS ANEMIA. 

This variety of anaemia, sometimes called idiopathic or essential, and, 
in virtue of its course, progressive, is characterized especially by an ex- 
cessive diminution of red blood- corpuscles and a not more than corre- 
sponding deficiency of haemoglobin. 

Etiology. — The term progressive pernicious anaemia is based upon 
the clinical course of certain cases ©£ anaemia of obscure origin. Easily ex- 
cluded are fatal cases of secondary anaemia from obvious causes, as profuse 
or repeated hemorrhages, whether from injury or from disease, and cancer 
or sarcoma of various organs. Atrophy of the mucous membrane of the 
stomach has been regarded as a satisfactory explanation for the concur- 
rent fatal anaemia. Eecent investigations have rendered it possible to 
eliminate from the group of pernicious anaemias those due to parasites, 
especially to the anchylostomum duodenale, while the filar ia sanguinis liominis 
and the distomum haematobium have long been known as causes of serious 
if not fatal anaemia. 

Pernicious anaemia in the limited sense occurs in both sexes, rather 
more frequently in the female, and is rare in childhood, although Griffith 
records the occurrence of ten cases under the age of twelve. Pregnancy 
and parturition have seemed to be exciting causes in many instances, 
while sudden or extreme mental shocks Have been important antecedents 
in other cases. 

Morbid Anatomy. —Conspicuous among the lesions found after death 
is the pale lemon-yellow color of the skin, with but little loss of sub- 
cutaneous fat-tissue. The blood is notably pale. The diffuse and speckled 
opaque yellow color of the heart is indicative of its fatty degeneration, 
and a yellow discoloration of the kidneys and liver is evidence of a like 
degeneration of these organs. Fatty degeneration of the glands of the 
stomach and intestine is also present. Hunter has called attention to 
an excess of iron, both as ferrated pigment and as colorless iron, in the 
peripheral region of the hepatic lobules. The kidneys also contain an 
excess of pigment. The spleen is sometimes enlarged. Lichtheim, Burr, 
and others have found secondary degeneration in the posterior columns 
of the spinal cord. Numerous minute hemorrhages, attributed to em- 
bolism of the smaller vessels, have been seen in the mucous and serous 
membranes and in the retina, sometimes in the skin. The marrow of 
the long bones is deprived of much of its fat, is red, gelatinous (lym- 
phoid), and contains numerous nucleated red blood-corpuscles, especially 
those of large size, — megaloblasts. 

Symptoms. — Vertigo, faintness, palpitation, and rapid breathing on 
slight exertion, loss of appetite, nausea, vomiting, epigastric pain, and 
constipation, sometimes diarrhoea, are the chief symptoms. They differ 
from those of secondary anaemia in being more persistent and progressive, 
until increasing debility results in confinement to the room, eventually to 



10 



GENERAL DISEASES. 



the dorsal position, and finally to the bed. The temperature is often 
elevated from 100° to 101° F., sometimes for a period of weeks. 

The extreme pallor of the visible mucous membranes and the skin, 
the latter being of a light lemon-yellow color, is conspicuous, while the 
absence of emaciation and the frequent presence of abundant subcutane- 
ous fat- tissue are striking. The pulsation of the heart is visible over an 
increased area, and a systolic or diastolic murmur is to be heard at the 
apex. Pulsation in the arteries at the base of the neck is often conspicu- 
ous, and a venous hum is to be heard on auscultation of the jugular vein. 
Cutaneous hemorrhages are occasionally to be seen, and retinal hemor- 
rhages are frequently found with the ophthalmoscope. The pulse is rapid 
and full, and its tension diminished. The urine is high-colored from an 
excess of urobilin, although numerous observations of a pale urine are re- 
corded, and the urea and urates are increased. A trace of albumin may 
be present in the later stages of this disease, and Yon Jaksch has noted 
the presence of peptonuria. 

Especial importance is to be attached to the examination of the blood. 
The red blood-corpuscles are diminished in number, and, in extreme 
cases, may be as few as two hundred and fifty thousand to the cubic mil- 
limetre. They show no tendency to form rouleaux. They vary widely in 
size and shape, microcytes and poikilocytes being numerous, and Browicz 
and Kollmann have observed active irregular contractions of the latter, 
Nucleated red blood-corpuscles — normoblasts — are increased in number ; 
but especial importance is to be attached to the presence of large nucle- 
ated red corpuscles, — megaloblasts, — which may exceed the former in 
number. Megaloblasts are also stated to have been found in large num- 
bers in anaemia from malaria and in that due to the presence of the 
anchylostomum, as also in a variety of severe anaemias which have not 
proved fatal. Despite the extreme diminution in the number of red 
blood-corpuscles, the loss of haemoglobin, which may fall below twenty per 
cent., is not in proportion, since the individual red blood- corpuscle is 
frequently more deeply colored than normal. The blood-plates may be 
increased or diminished in number, and, although the leukocytes are 
apparently increased from the loss of red corpuscles, and Litten states 
that a transitory leukocytosis may occur, they are not permanently in- 
creased in number. 

Diagnosis. — The progressive character of the severe symptoms, and 
the absence of a satisfactory cause, are of especial importance in the differ- 
ential diagnosis between the various forms of secondary anaemia and per- 
nicious anaemia. The diagnosis is confirmed by the recognition of retinal 
hemorrhages, and established by the results of the examination of the 
blood, especially by the discovery of a greater number of megaloblasts 
than-of microblasts. 

Prognosis. — Progressive pernicious anaemia is almost invariably fatal 
within the course of one or two years. The reported cases of recovery 



DISEASES OF THE BLOOD. 



11 



are to be doubted, since temporary improvement is possible, and recovery 
may take place from the graver forms of secondary ansemia, the diagnosis 
of which is capable of being confounded with that of pernicious anaemia 
until the terminal stages of the latter affection. 

Treatment. — In pernicious anaemia systematic exercise, high feed- 
ing, out-door life, the rest-cure, all hygienic measures which seem indi- 
cated in the individual case, should be insisted upon. Iron and tonics 
are of no avail. The only remedy concerning whose power there is any 
favorable testimony is arsenic. It should be given after meals in the form 
of Fowler's solution, beginning with doses of two drops, steadily but 
slowly increased until a drachm or even a drachm and a half is taken each 
day, unless intolerance previously occur. The arsenic is generally well 
borne, but should be temporarily withdrawn when it disturbs the diges- 
tive tract. Slight puffiness of the face should not cause the withdrawal 
of the drug unless the urine contain albumin. Some practitioners prefer 
to give the arsenic hypodermically : five minims of Fowler's solution 
diluted with ten minims of water may be injected once a day, and in- 
creased as borne. Bone- marrow has been used with alleged excellent 
results. Eed marrow from the small bones of calves or other young ani- 
mals should be taken, since the marrow of long bones from old animals 
is chiefly fat. The raw marrow, in capsule, or a glyceride, may be used. 

LEUKOCYTOSIS. 

Definition. — A temporary increase in the number of leukocytes, 
especially of the polynuclear variety, in the blood. 

The blood normally contains about six thousand white blood-corpuscles 
to the cubic millimetre, and since the discovery by Ehrlich of the dif- 
ferences in their structure and in their behavior towards staining fluids, 
their relation to health and disease has been investigated by numerous 
observers. 

A distinction is to be drawn between a physiological and a pathological 
leukocytosis. The former is found to take place during digestion, begin- 
ning a short time after eating. It is also present in infants and young 
children, and in pregnancy. Exercise, massage, and baths are productive 
of an apparent increase in the number of white blood- corpuscles, which, 
however, may be due, as suggested by Thayer, to a local active congestion 
of the cutaneous vessels, and a corresponding increase in the presence of 
leukocytes. 

A pathological leukocytosis has been observed in a great variety of 
conditions. It is frequent during the death-agony, possibly from a pas- 
sive congestion due to an enfeebled heart, and has been found after hemor- 
rhage. It has been repeatedly observed in inflammatory affections of the 
skin, including those which are the local manifestations of an exanthem 
(with the exception of measles), and in numerous infectious diseases, in 
suppurative processes, and in malignant disease. Its absence is con- 



12 



GENERAL DISEASES. 



spicuous in malaria, typhoid fever (with rare exception), tuberculosis, 
and intestinal obstruction. 

The presence or absence of a leukocytosis has a definite clinical value 
both in diagnosis and in prognosis. The constancy of its presence in 
pneumonia may enable the diagnosis to be made in central pneumonia 
when typical physical signs are absent. Of still greater diagnostic impor- 
tance, since it directly leads to the appropriate treatment, is its value in 
the recognition of deep-seated suppuration. E. C. Cabot mentions its con- 
stant presence in suppurative salpingitis, and states that this affection may 
thus be differentiated from hsematoma and hematocele, and from uterine 
and ovarian tumors. The recognition of leukocytosis may be of value in 
permitting the diagnosis of an osteomyelitis. In about one-half of the 
cases of malignant disease examined by Rieder and Hayem leukocytosis 
was present ; and according to Sadler it may be extreme, sixty to ninety 
thousand in the cubic millimetre, or may be entirely absent. The leu- 
kocytosis of malignant disease is more frequent in sarcoma, especially 
osteosarcoma, than in cancer. When the uterus is affected with cancer 
leukocytosis is more frequent than in cancer of the breast, stomach, or 
oesophagus. The usual absence of leukocytosis in typhoid fever may 
permit the exclusion of this disease in a case of questionable nature, — for 
example, acute appendicitis. The occurrence of leukocytosis in typhoid 
fever has led to the recognition of a complicating pleurisy or pneumonia. 
Its absence may also prove of diagnostic importance in the exclusion 
of malaria and uncomplicated acute tuberculosis, in which affections the 
leukocytes are not increased. A failing leukocytosis in case of doubt 
would permit acute intestinal obstruction to be differentiated from a 
general peritonitis, in which affection leukocytosis is present. 

The degree of leukocytosis is no evidence of the severity of the disease 
concerned. In pneumonia it is present, as a rule, throughout the disease 
despite the pseudo-crises, persisting not infrequently for several days after 
the temperature has fallen, apparently being closely related to the process 
of resolution. An absence of leukocytosis in pneumonia is a grave prog- 
nostic sign, death usually occurring in such cases. 

LEUKEMIA. 

Definition. — A permanent increase in the number of the white blood- 
corpuscles in the blood, associated with lesions of the spleen, lymphatic 
glands, or bone-marrow. 

Etiology. — But little is known concerning the cause of leuksemia. 
It occurs more often in males than in females, especially in adults, and is 
rare in infants and in old age. It is more frequent among the poorer 
classes, and is epidemic and endemic in certain countries. Its repeated 
presence in connection with pregnancy, malaria, syphilis, pernicious 
anaemia, chronic diarrhoea, and injuries to the spleen and bones has 
suggested that these affections may be of etiological importance. The 



DISEASES OF THE BLOOD. 



13 



occasional rapid course and the associated lesions resemble those of an 
infectious disease, and bacteria have been suggested as a cause, but with- 
out any positive evidence of value. Auto-intoxication from the digestive 
tract has also been mentioned as of importance in the etiology. 

Mokbid Anatomy. — The organs especially diseased are the spleen, 
lymphatic glands, and bone-marrow : hence splenic, lymphatic, and mye- 
logenous varieties of leukaemia are discriminated. Combined lesions are 
not infrequent, particularly of the spleen and lymph-glands, whence the 
term spleno- or lieno-lymphatic leukaemia. A purely lymphatic leu- 
kaemia is rare, and a purely myelogenous leukaemia is of doubtful occur- 
rence. The spleen may be enormously enlarged, weighing sixteen pounds, 
the enlargement being due to a hyperplasia, either diffused or nodular. 
Its color is red or reddish brown, sometimes modified by the presence of 
tumors, hemorrhage, and fatty degeneration, and its density is increased. 
The enlargement is either symmetrical or nodular, and on section opaque- 
gray tumors, leukaemic lymphomata, of various size and number, may be 
present. The lymph-glands in the various regions of the body may be- 
come so enlarged as to cause extreme degrees of deformity. The hyper- 
plastic glands are soft or hard, of an opaque-gray color on section. They 
may vary considerably in size, and may be discrete or agglutinated. The 
tonsils, the lymphatic glands at the base of the tongue, the solitary fol- 
licles, and Peyer's patches may show like alterations. Similar nodules, 
leukaemic lymphomata, may be found in the heart, liver, kidneys, retina, 
brain, cord, lungs, pleurae, and skin. The liver and kidneys may become 
enlarged from a diffuse infiltration with the lymphomatous tissue, and a 
thus affected liver is reported to have weighed forty-two pounds. The 
alterations of the bone- marrow consist in a disappearance of the fat and 
an increase in the number of nucleated red blood- corpuscles, — lymphoid 
marrow, — or in an increase of the large mononuclear marrow-cells, — mye- 
locytes, — which in combination with the excess of leukocytes produce an 
opaque-yellow appearance, — the pyoid or puriform marrow. Evidences 
of hemorrhage in various parts of the body may be found, and dropsy 
is frequent. The blood has a pale pink color, and the clot found in the 
heart is soft, gelatinous, and sometimes so suggestive of pus as to have 
led Bennett to regard the disease as a suppuration of the blood, — pyaemia. 
This alteration in the color of the blood is due partly to the increase in 
the number of leukocytes, and partly to a deficiency of red corpuscles. 
The former may even exceed in number the latter, which in normal 
blood are at least five hundred times as abundant as the leukocytes. 
Charcot- crystals may form, on exposure to the air, in the blood, bone- 
marrow, spleen, and liver. 

Symptoms. — The incipient symptoms of leukaemia are due to deficient 
haemoglobin, and are essentially those of anaemia, — namely, headache, de- 
bility, shortness of breath, palpitation, obscure abdominal pain, pallor, 
and slight oedema. These symptoms become more severe when enlarge- 



14 



GENERAL DISEASES. 



ment of the spleen or lymph-glands is apparent. The pallor becomes 
more extreme, the appetite fails, diarrhoea may occur, and loss of flesh, 
as well as of strength, is conspicuous. Hemorrhages are frequent in 
various parts of the body, either from the nose, stomach, intestine, or 
urinary or genital tract, or into the lungs, brain, or skin. Hemorrhage 
into the retina may obscure vision, while hemorrhage into the auditory 
nerve may be a cause of deafness. Obscured sight and hearing may also 
result from a lymphomatous growth in the retina or the labyrinth, and 
Gannoie has recently recorded symptoms resembling those of Meniere's 
disease from leuksemic growths in the ear. Priapism is an occasional 
symptom, sometimes lasting several weeks, and has been attributed to a 
passive venous congestion from the pressure of the enlarged spleen. The 
pulse is increased in frequency, and is of diminished tension. Respira- 
tion is accelerated, in part from the deficiency of red blood- corpuscles, 
and in part from the obstruction to the descent of the diaphragm when 
the spleen is enlarged. The temperature may be normal or at times ele- 
vated one or two degrees. Anaemic murmurs may be heard on auscul- 
tation of the heart. The urine is abundant, high-colored, 1020 to 1027, 
and the urates are increased. 

The enlargement of the lymphatic glands is usually first seen in the 
neck, the glands in the axillae, groins, and abdomen being subsequently 
diseased. The swollen glands are neither painful nor tender, but may 
press upon neighboring parts, as the veins, causing oedema, or upon the 
trachea or bronchi, producing dyspnoea. The enlargement of the spleen 
often produces a conspicuous distention of the abdomen. According to 
the degree of enlargement its outline is more or less easily determined. 
The lower edge may lie in the pelvis, the anterior border may extend 
beyond the navel, and a notched edge is often to be appreciated. Local- 
ized tenderness of the surface of the spleen, the result of peritonitic 
adhesions, may exist. In acute leukaemia these symptoms develop in the 
course of a few weeks, whereas in chronic leukaemia the process extends 
over months or years. 

The blood is characterized by the excess of white blood- corpuscles, 
the increase in the number of which is due chiefly to the presence of 
the large mononuclear variety. The polynuclear leukocytes and eosino- 
philes are also increased in number, while the percentage of the small 
mononuclear lymphocytes is diminished. The leukocyte especially char- 
acteristic of leukaemia, according to Ehrlich, is the large granular mono- 
nuclear neutrophile, almost never found in normal blood, but only in the 
bone-marrow, whence the term myelocyte. These cells have no amoeboid 
movement, and, although significant of leukaemia when many are present, 
they may be absent in this disease. The red blood-corpuscles are dimin- 
ished in number, abnormally pale, vary in size and shape, and nucleated 
red blood- corpuscles, both small and large, may be absent or numerous. 
Charcot- crystals may be found, especially in blood rich in eosinophiles. 



DISEASES OF THE BLOOD. 



15 



In the examination of the blood it is important to discriminate be- 
tween a leukocytosis and a leukaemia. For this purpose the relative pro- 
portion of red to white corpuscles is of no value except in extreme cases, 
since a proportion of one leukocyte to twenty red corpuscles has been 
found in leukocytosis. In leukocytosis the total number of red blood- 
corpuscles is usually relatively normal, in leukaemia it is markedly di- 
minished. In leukocytosis, according to Ehrlich, there is a dispropor- 
tionate excess of polynuclear leukocytes, which normally constitute 
three-fourths or two-thirds of the total number of leukocytes. It may be 
impossible from the examination of the blood alone to make a diagnosis 
of leukaemia in its early stage or when myelocytes are absent. The 
characteristics of the blood may vary from time to time. A predomi- 
nance of the large mononuclear forms is suggestive of a conspicuous 
affection of the spleen, while an excess of the small mononuclear forms 
indicates an affection of the lymphatic glands, and abundant myelocytes, 
— myelaemia, — if occurring, would indicate a conspicuous medullary or 
myelogenous leukaemia. According to Fraenkel, the blood of acute leu- 
kaemia is distinguished from that of chronic leukaemia by a preponder- 
ance of large and small mononuclear leukocytes and an excessive diminu- 
tion of the polynuclear variety. In chronic leukaemia there is an increase 
of all varieties in addition to the presence of the myelocytes. The ex- 
istence of changes in the bone-marrow is favored by conspicuous tender- 
ness of the bones, although Litten denies the diagnostic importance of 
this symptom. 

Diagnosis. — The results of the physical examination of the blood 
determine the diagnosis of leukaemia, although enlargement of the spleen 
or lymph-glands with symptoms of anaemia may suggest its presence. 
Leukaemic blood has been found in cases in which there were no altera- 
tions of the spleen and lymphatic glands, and in pseudo -leukaemia en- 
largement of the spleen or lymphatic glands is present without increase 
of the leukocytes. The diagnosis of the especial variety of leukaemia 
depends upon the results of the physical examination of the spleen, 
glandular regions, and bones, as well as of the blood. The distinction 
between leukocytosis and leukaemia based on the examination of the 
blood has been mentioned above. 

Prognosis. — Leukaemia is generally considered to be a fatal disease, 
although cases of recovery are occasionally reported. Some of these are 
perhaps cases of leukocytosis, while others may represent a not infre- 
quent temporary improvement which may extend over a period of months. 
Acute leukaemia is usually of the lymphatic type with abundant small 
and large lymphocytes, and may terminate fatally in the course of a 
few weeks. Osier, however, mentious a case of leukaemia of ten years' 
duration in which, at the end of this time, ninety per cent, of the leuko- 
cytes were lymphocytes. Chronic leukaemia is the variety usually seen : 
it generally extends over a period of two years or more, death eventually 



16 



GENERAL DISEASES. 



resulting froin progressive weakness ending in x>ulnionary oedema or a 
complicating pneumonia. 

Treat]\ient. — The treatment of leukaemia is the same as that of 
pseudo-leukaemia (see page 19). 

Excision of the spleen has been performed twenty-five times, with 
twenty -four deaths, and is hardly a justifiable operation. 

CHLOROMA. 

This term is applied in virtue of its green color to a tumor which pre- 
sents a lymphadenoid structure. It occurs in multiple form in various 
parts of the body, not especially in the lymphatic glands or the spleen, and 
is associated with a profound anaemia and with a condition of the blood 
analogous to that found in leukaemia, the leukocytes being increased as 
one to five. Dock has recently published an article showing the intimate 
relation between chloroma and leukaemia. Tumors are found especially 
at various parts of the head, but also in the internal organs. In the 
former situation, although presenting the characteristics of sarcoma of the 
bone, they apparently do not arise from the periosteum. With their ex- 
tension throughout the body the clinical characteristics are those of a 
leukaemia, especially of the lymphatic type, which it further resembles 
in the large proportion of lymphocytes in the blood and in the rapidity 
of its course, death usually occurring in the course of a few months. 
It differs from leukaemia in the slight alterations of the lymph-glands 
and spleen, although the thymus is not infrequently diseased. 

In children enlargement of the spleen and lymphatic glands associated 
with anaemia has been found by Yon Jaksch to be acconrpanied with a 
persistent leukocytosis. He applies the term pseudo-leukaemic anaemia 
to these cases, since the lesions characteristic of leukaemia were not found 
at the autopsy. 

PSEUDO-LEUKEMIA. 

Definition. — A disease characterized by persistent and progressive 
anaemia, enlargement of the spleen or lymphatic glands or of both, but 
without an excess of leukocytes, whence the designation pseudo-leukaemia. 

Synonymes. — Hodgkin's disease, malignant lymphoma, malignant 
lympho- sarcoma, lymphadenoma, adenie, splenic anaemia, lymphatic 
anaemia. 

Etiology. — Nothing definite is known concerning the origin of this 
disease. In certain cases local irritation has seemed important, since the 
glands first enlarged were those receiving lymph from an irritated region. 
An infectious origin has recently been suggested by Ebstein from the oc- 
currence of cases in which a chronic relapsing fever, splenic enlargement, 
and multiple lymphomata in the viscera were associated. Malaria, syph- 
ilis, and tuberculosis have been assigned an etiological importance. An 
intimate relation between certain cases of malignant lymphoma and 
pseudo- leukaemia is suggested by a generalization of the former, while the 



DISEASES OF THE BLOOD. 



17 



rare termination of pseudo -leukaemia in leukaemia is indicative of an 
intimate relation, at times, between the latter affections. H. C. Wood, in 
1871, observed that every grade exists between a pronounced leukaemia 
and a strict pseudo -leukgemia, and that the same patient at one time may 
show the characteristics of the one disease, while at a later period the phe- 
nomena of the other are presented. The disease occurs more often in male 
infants, children, and adults, less frequently in the aged and in females. 

Morbid Anatomy. — The variations in the shape, size, and consist- 
ency of the glands found in leukgemia are to be met with in pseudo-leu- 
kaemia, and there is but little tendency to suppuration or degeneration. 
The longer the enlargement of the glands persists, the more likely are 
they to be found dense and agglutinated. The glandular affection usu- 
ally occurs first in the neck, then in the axillary, inguinal, retroperi- 
toneal, mediastinal, and mesenteric glands. These groups of glands may 
become diseased in continuous sequence, or conspicuous alterations of 
remote regions may exist, the intervening glandular collections being rela- 
tively normal. In some cases the superficial glands may show but little 
change, and the deep-seated glands, especially the mediastinal and the 
retroperitoneal, may become extensively diseased. To this variety the 
term lymphatic ancemia is applied. 

When the spleen was conspicuously and exclusively altered the term 
splenic ancemia has been applied, but there is no essential difference be- 
tween the alterations of the spleen when alone affected and when the 
lymphatic glands are also diseased. The spleen, as in leukaemia, is en- 
larged, either symmetrically or from the presence of tumors, lymphomata, 
varying in size and number. The degree of enlargement varies con- 
siderably, being less when the lymph- glands are simultaneously diseased 
than when they are free from alterations. 

Abnormalities of the bone-marrow are infrequent, although it may 
become red, lymphoid, and may contain lymphomatous nodules. As in 
leukaemia, so in pseudo-leukaemia a pure myelogenous form is of doubt- 
ful occurrence. In advanced cases of this disease multiple lymphomata 
may be found not only in the spleen and bone- marrow, but also in the 
skin, tonsils, thymus gland, stomach, intestine, liver, kidneys, lungs, 
central nervous system, and retina. 

Symptoms. — Enlargement of the cervical lymph-glands is usually first 
noticed. With their increase in size and number similar enlargements 
of the axillary and inguinal glands are observed. The patient then be- 
comes pale, and suffers from the familiar symptoms of anaemia, as palpi- 
tation, shortness of breath, disturbed vision, ringing in the ears, failing 
appetite, and loss of flesh and strength. Eventually hemorrhages and 
oedema may occur, and obstinate itching of the skin has been observed. 
With increasing anaemia the patient may become delirious or comatose. 
An elevated temperature is frequent, even at the outset, and there may 
be exacerbations and remissions at regular intervals. 

2 



18 



GENERAL DISEASES. 



Pressure- symptoms are important, especially when the internal lym- 
phatic glands are diseased. Pressure upon the superficial veins gives 
rise to local oedema, dilatation of the veins, and ulceration of the skin. 
Dyspnoea results from pressure upon the larynx or trachea, and may be 
of an asthmatic character when the bifurcation of the trachea is involved. 
Dysphagia occurs from pressure on the oesophagus. Deafness may result 
from lymphomata in the pharynx. Hoarseness may follow pressure on 
the recurrent laryngeal, and palpitation may result from involvement of 
the pneumogastric nerve. Pain may arise from pressure upon the sen- 
sitive nerves, and irregular pupils from pressure upon the cervical sym- 
pathetic nerve. When the abdominal glands are enlarged, ascites and 
jaundice may result from pressure on the portal vein and bile- ducts. 
Bronzing of the skin sometimes occurs, and pressure upon the inferior 
vena cava has produced extensive oedema of the legs. The enlarged 
glands may diminish somewhat during intercurrent febrile attacks, and 
especially towards the end of life. 

The enlarged spleen is readily palpated, but rarely extends below the 
level of the navel. 

The blood shows a deficiency of red blood- corpuscles and haemoglobin 
corresponding to the degree of anaemia. Poikilocytosis is inconsider- 
able, and normoblasts are not especially numerous. The main feature 
in connection with the lesions is the absence of leukocytosis, although 
in rare instances the blood may assume a leukaemic character from an 
excessive formation of lymphocytes, a condition which has suggested that 
pseudo-leukaemia may represent an aleukaemic stage of leukaemia. 

Diagnosis. — Pseudo-leukaemic hyperplasia of the lymphatic glands 
may be mistaken for enlargement due to tuberculosis, leukaemia, or be- 
nignant lymphoma ; and A. K. Stone has repeatedly seen an irritative 
lymphadenitis from vermin mistaken for pseudo -leukaemia. Inflamed 
and tubercular glands are usually limited to a single region, are less 
freely movable, and the latter are prone to caseation, softening, and 
evacuation with the formation of sinuses. Leukaemic lymphomata are 
to be differentiated by the examination of the blood. Benignant lym- 
phoma is to be differentiated by persistence of the tumor without exten- 
sion, and by the absence of anaemia or pressure-symptoms. Time alone 
suffices to make the differential diagnosis clear. 

The splenic variety of pseudo-leukaemia is to be recognized from the 
association of the palpable enlargement of the spleen with the symptoms 
of anaemia. Leukaemic enlargement of the spleen is excluded by the 
examination of the blood. The lacking history of malaria eliminates 
hyperplasia, and amyloid enlargement of the spleen may be excluded by 
failing evidence of this disease elsewhere, and by the absence of symp- 
toms or signs of tuberculosis and syphilis, the usual antecedents of 
amyloid degeneration. 

Prognosis. — Permanent recovery from pseudo -leukaemia is rare, 



DISEASES OF THE BLOOD. 



19 



although temporary improvement with diminution in the size of the 
glands may take place. The removal of a localized collection of enlarged 
glands which may have produced a deformity for a number of years is 
often followed by the rapid development of pseudo-leukaemia. The dura- 
tion of the disease varies : some cases run a rapid course, terminating 
fatally within a few weeks, while others, the rule, extend over a period 
of several years. Oases in which a conspicuous involvement of the in- 
ternal lymphatic glands exists are more rapidly fatal than those in which 
the superficial glands are especially diseased. 

Treatment. — The treatment is the same as that of pernicious 
anaemia. (See page 11.) 

When there are enlarged glands the local use of arsenic is believed 
by some authorities to bring about disintegration of diseased tissue. 
Each day there should be injected into a gland not before treated a 
mixture of equal parts of fresh Fowler's solution and of a two per cent, 
solution of carbolic acid in water. The first dose should be four drops, 
and an additional drop should be added daily until twenty drops are 
reached or toxic symptoms are produced. There may be no immediate 
disturbance, or there may be local pain for some hours afterwards. Cu- 
taneous inflammation or abscess may follow, or temporary enlargement 
of the gland, and oedema. As an immediate result of the treatment, the 
patient may suffer from a bad taste in the mouth, a burning in the throat, 
thirst, loss of appetite, nausea, vomiting, diarrhoea, abdominal pains, and 
jaundice. The temperature and pulse may rise. These symptoms de- 
mand temporary cessation of the treatment. If the glandular swellings 
return, a renewal of the treatment is indicated. 

MYELOMA. 

Von Eecklinghausen has recently applied this term to designate a 
tumor of a lymphadenoid type arising in the bone-marrow. Its structure 
resembles that of the pyoid marrow found in leukaemia, but its blood- 
vessels have no defined walls, and its cells and their nuclei are larger. It 
differs in the manner of its growth, since it produces enlargement, ab- 
sorption, and perforation of the bone, with extension to the neighboring 
parts, which do not occur in the leukaemic affections of the bone-marrow. 
Its clinical course is like that of pseudo-leukaemia, and is manifested by 
progressive anaemia with the formation of multiple nodules in various 
parts of the body. Leukocytosis is usually absent, but in a single case 
presenting the other characteristics of myelaemia a sudden invasion of 
the blood with leukocytes took place. 

HEMORRHAGIC DIATHESIS. 

This expression includes a variety of conditions in which hemorrhages, 
usually multiple, in the skin, from mucous membranes, and in various 
organs and tissues of the body, are a common characteristic. This series 



2fl 



GENERAL DISEASES. 



includes factors which are evidently of congenital and inherited origin, 
as well as others which are acquired. On the one hand, conspicuous 
importance is to be attached to errors in diet and faulty hygienic sur- 
roundings, while, on the other, the probability of the action of various 
infectious agents is strongly suggested. 

It is important to eliminate from the series of diseases under consid- 
eration those conditions in which multiple hemorrhages represent a result 
of well-recognized causes. These are usually included under the term 
symptomatic purpura, since the purple spots resemble those occurring in 
the disease purpura, the cause of which is not well denned. . Such symp- 
tomatic hemorrhages occur in consequence of infections, poisons, chronic 
diseases with conspicuous nutritive disturbance, vaso-motor affections, 
and mechanical passive congestions. 

In the infectious group of symptomatic hemorrhages are included 
those occurring in the so-called black, malignant, or hemorrhagic scarlet 
fever, measles, and small-pox. The hemorrhagic condition is also seen in 
typhus and typhoid fevers, relapsing fever, Oriental pest, cerebro-spinal 
meningitis, acute articular rheumatism, acute ulcerative endocarditis, 
influenza, septicaemia, puerperal infections, yellow fever, and cholera. In 
this series also probably belong the hemorrhages which occur in acute 
yellow atrophy. 

The toxic causes of symptomatic, circumscribed hemorrhage are snake 
poison, and various drugs, as potassium iodide, phosphorus, mercury, 
copaiba, ergot, quinine, chloral, belladonna, and alcohol. 

The cachectic group includes syphilis, tuberculosis, cancer, nephritis, 
fibrous hepatitis, pernicious anaemia, leukaemia, and pseudo-leukaemia. 
Yaso-motor or neurotic hemorrhages may occur in acute and chronic 
myelitis, multiple neuritis, sometimes in neuralgia, and is most conspicu- 
ously seen in the rare cases of stigmata. Cutaneous hemorrhages from 
passive congestion are especially seen in spasmodic affections like whoop- 
ing-cough and epilepsy. 

The diseases in which hemorrhage is a conspicuous characteristic are 
haemophilia, scurvy, purpura, and haemoglobinaemia. 

HEMOPHILIA. 

Definition. — A congenital tendency towards multiple hemorrhages 
occurring either spontaneously or from trifling injury, often in persons 
otherwise in good health. 

Etiology. — Heredity is the only known cause of haemophilia. Hoessli 
has found evidence of its occurrence in the same family for two hun- 
dred and fifty years. The male members are more often affected than the 
females, although the tendency to bleed is usually transmitted through 
the latter, even where they are not bleeders. 

Morbid Anatomy. — No satisfactory anatomical basis for the occur- 
rence of the hemorrhage has been found. Yirchow has suggested that the 



DISEASES OF THE BLOOD. 



21 



pressure of an excess of blood upon the delicate wall of blood-vessels 
of insufficient capacity may produce the hemorrhage. Abnormally thin 
vascular walls have been found, and an increased number of red blood- 
corpuscles has also been observed. Clotted blood may be detected 
attached to mucous surfaces when copious hemorrhage has occurred. 

Symptoms. — The hemorrhages are mild or severe, usually a slow 
capillary oozing, and may occur as petechiae or as bleeding from mucous 
surfaces, especially in the nose and from the gums. Bleeding may also 
take place from the stomach, intestine, or urinary tract. Senator has 
reported a case of unilateral renal haemophilia in a female, diagnosticated 
by means of the cystoscope, and cured by removal of the kidney. Hem- 
orrhage from the genital tract may be excessive during menstruation or 
after delivery. Hemorrhage into the joints, especially the large joints, is 
not infrequent, and may be associated with swelling, pain, and fever sug- 
gesting rheumatism. The local symptoms may disappear, or an inflam- 
mation of the affected joint follow with permanent deformity which may 
be mistaken for articular tuberculosis. 

The existence of haemophilia is usually made known in early child- 
hood, and may be manifested immediately after birth by severe umbilical 
hemorrhage. Slight causes, as bruises, scratches, needle-pricks, cuts, and 
especially the pulling of teeth, may serve to produce severe, even fatal, 
hemorrhage. 

Diagnosis. — Haemophilia is to be diagnosticated when frequent and 
obstinate multiple hemorrhages from trivial causes occur, especially in one 
whose ancestors have had a similar history. If deformity of the joints 
results, it is to be distinguished from a tuberculosis of the joints by the 
absence of a tendency to suppuration and the formation of sinuses. 

Prognosis. — Mild and severe cases of haemophilia occur. The latter 
may prove fatal in the course of twenty-four hours. The tendency to 
hemorrhage may disappear in adult life, while frequent and profuse 
hemorrhages produce a debility which is the frequent cause of the early 
death of haemophilic children. 

Treatment. — The treatment of haemophilia is exceedingly unsatis- 
factory, as there are no known drugs which possess the power of altering 
the inherited tendency, and whilst extract of ergot, oil of erigeron, plum- 
bic acetate, gallic acid, aromatic sulphuric acid, and the whole list of 
anti-hemorrhagic drugs may be used when hemorrhage occurs, their 
controlling power is slight. Whenever it is possible the flow of blood 
should be arrested by mechanical measures. The exhaustion and anaemia 
which follow excessive bleeding are to be treated upon general principles. 
The children of such families as suffer through successive generations 
should by physical culture, open-air life, careful feeding, and other well- 
known methods be rendered as robust as possible ; although it is doubtful 
whether the most careful hygienic treatment from early infancy will 
overcome the constitutional inheritance. 



22 



GENERAL DISEASES. 



In hemophilic patients the greatest care should be taken to prevent 
abrasions or wounds, and the slightest surgical procedure, even vaccina- 
tion or the pulling of a tooth, ranks in its danger as a major operation. 

SCURVY. 

Definition. — A disease characterized by mental and physical weak- 
ness, anaemia, and frequent hemorrhages, generally occurring among a 
number of people in a limited locality. 

Etiology. — Scurvy is a disease usually found among sailors or sol- 
diers, prisoners or paupers, or among travellers, especially in the Arctic 
regions. A number of persons exposed to like conditions are usually 
affected. Although epidemics and endemics of scurvy are the rule, iso- 
lated cases may occur. The best recognized cause is unsuitable food, es- 
pecially too exclusive a diet. Especial prominence has been assigned to 
a lack of potassium salts, since many sufferers have been obliged to live 
for a long time on salted and corned foods in which these salts are lacking. 
The relief afforded in such cases by fresh meats and a vegetable diet seems 
an argument in favor of this view, but scurvy may arise among vege- 
tarians, and may be absent among people in the polar regions whose diet 
contains no vegetables. Although especial importance is to be attached 
to an exclusive diet, favoring causes are to be found in faulty hygienic 
surroundings, excessive mental and physical exertion, and, particularly, 
mental depression. The possibility of an infectious origin for certain 
epidemics and endemics in Eussia is strongly maintained. The term in- 
fantile scurvy has been applied of late years to a dietetic hemorrhagic 
disease of infants which in this work is designated hemorrhagic rickets. 
(See page 55. ) 

Morbid Anatomy. — The anatomical changes are primarily those due 
to hemorrhages, cutaneous, subcutaneous, intramuscular, and within and 
in the neighborhood of the joints. They are also to be found in the 
mucous membranes of the digestive, bronchial, and urinary tracts, in 
the serous membranes, in the serous cavities, and within the kidney. 
Swollen and sloughing gums are especial characteristics of the disease. 
A hyperplastic spleen and parenchymatous degeneration of the heart, 
liver, and kidneys are also present. 

Symptoms. — The hemorrhages occurring in scurvy are usually pre- 
ceded by a gradual loss of flesh and strength, associated with failing 
appetite and symptoms of anaemia. After a week or more of malaise, 
multiple cutaneous hemorrhages make their appearance, at first, usually, 
in the legs. The hemorrhages are petechial, or occur as patches or flat- 
tened nodules. As a rule, the gums, especially near the teeth, soon be- 
come affected, and are swollen, soft, and spongy, bleeding freely, and 
tending to become gangrenous. The teeth are likely to become loose, 
and may drop out. Hemorrhages also take place from the several mucous 
membranes, the respiratory mucous membrane being the least often af- 



DISEASES OF THE BLOOD. 



23 



fected. Bleeding from the nose and month is the most freqnent. Bleed- 
ing may also take place into the muscles, joints, and serous cavities. 
Pains are frequent both in the trunk and in the extremities, and are some- 
times referred to the region of the joints, but are not dependent upon 
local hemorrhages. As the disease progresses the prostration becomes 
extreme. There are palpitation and dyspnoea on slight exertion. The 
skin becomes cedematous. Ulcers arise due to hemorrhages, or to in- 
flammation of scars of previous injuries. Necrosis of bone may take 
place, whilst acute inflammation of the serous membranes, lungs, or kid- 
neys is not infrequent, and may prove the immediate cause of death. In 
such cases the temperature is elevated, although in the absence of febrile 
complications it is either normal or subnormal. In the later stages of 
the disease the patient may become sleepless and delirious, and may 
suffer from night-blindness or day-blindness, convulsions, or paralysis. 

The skin is dry and scaly, and in certain epidemics may present an 
erythematous, vesicular or papular eruption. The tongue is red and 
swollen, the breath fetid. The pulse is soft, not increased in frequency. 
A systolic murmur is heard over the heart. The examination of the 
blood shows a diminution in number and variation in size of the red 
blood-corpuscles, and the diminution in haemoglobin characteristic of 
anaemia. According to Henry, the blood-count varies between two and 
five millions, according to the severity of the disease. The urine is 
dark-colored, has a high specific gravity, and, in severe cases, contains 
albumin. 

Diagnosis. — The diagnosis of scurvy depends upon the coexistence 
of malaise and weakness with a tendency to hemorrhages from the mucous 
membranes and under the skin : a peculiar lividity of the spongy gums 
should always arouse suspicion, unless there be other disease to account 
for it. When a number of persons exposed to like conditions are simul- 
taneously affected the diagnosis is plain ; but even in an isolated case the 
true nature of the disease should be suspected and a correct decision be 
arrived at by noting the beneficial effect produced by a suitable change 
of diet. 

Prognosis. — Becovery usually takes place, provided appropriate 
treatment can be applied before the later stages of the disease are reached, 
although convalescence is likely to be prolonged. In fatal cases death 
may occur either suddenly from intracranial hemorrhage or from syncope 
during undue muscular exertion, or more gradually from intercurrent 
disease, as inflammation of the lungs, serous membranes, or intestine. 

Treatment. — In the treatment of scurvy drugs are of very second- 
ary importance, even for the relief of symptoms. Tonics, astringents, 
especially sulphuric acid, and alcoholic and other stimulants, may be 
used to overcome failure of appetite, tendency to bloody fluxes, debility, 
and cardiac weakness, but will rarely act effectually ; whilst these symp- 
toms will of themselves rapidly yield to the proper treatment of the 



24 



GENERAL DISEASES. 



underlying condition. Mercurials, alkalies, and all depressing remedies 
are absolutely contra-indicated. 

Lemon juice or its equivalent lime juice may be considered a specific 
for the disease ; from one to two ounces should be given every two to 
four hours, diluted with an equal amount of water. When obtainable, 
the juice of fresh lemons is preferable to the preserved juice, though the 
latter acts favorably. No artificial imitation is of any value. There is no 
possible contra-indication for its use : the more severe the gastro-intestinal 
disturbance the more rapidly it should be administered. Next to lemon 
juice in effectiveness come fresh vegetables ; especially active are various 
cruciferous plants, some of which on account of their growing in remote 
Arctic or Antarctic regions have been so much used as to have especial 
reputation. Lettuce, spinach, sorrel, celery, and any vegetable which is 
taken raw should be eaten freely. Cooked vegetables are distinctly less 
active. Thus, it is doubtful whether potatoes used in the ordinary 
methods have any influence over the disease ; but scraped raw pota- 
toes have in various emergencies saved life. Apples and other fruits 
are active antiscorbutics. Any young plants which can be digested 
should be used when the more suitable foods are not attainable. Fresh 
air and absolute quiet are useful, but not essential, in the treatment of 
the disease. 

PURPURA. 

Definition. — A disease characterized by multiple hemorrhages with- 
out obvious cause, frequently associated with rheumatic pains and lesions 
of various degrees of severity. 

It is probable that a number of diseases of differing etiology are in- 
cluded under this designation, although there are only three varieties 
usually classified as presenting common as well as individual character- 
istics. These are simple purpura, rheumatic purpura, and hemorrhagic 
purpura. 

SIMPLE PURPURA. 

Simple purpura occurs oftenest in children, sometimes in old people, 
and may be found among both the weak and the strong. It is character- 
ized by the presence of multiple, circumscribed, cutaneous hemorrhages, 
either petechia} or ecchymoses, especially the former, which may be lim- 
ited to the extremities, particularly the lower, or distributed over the 
entire body. Internal hemorrhages are usually absent, yet hematuria is 
sometimes observed. 

Symptoms. — There is but little constitutional disturbance, although 
loss of appetite, diarrhoea, debility, muscular pains, and slight eleva- 
tion of temperature may be present. When muscular pains and sensi- 
tive joints occur, this variety resembles the milder forms of rheumatic 
purpura. 

Diagnosis. — Purpura is to be distinguished from scurvy by the 



DISEASES OF THE BLOOD. 



25 



mildness of its symptoms and by the absence of the peculiar changes in 
the gums, as well as of the tendency to ulceration of the soft tissues, to 
inflammation of mucous membranes and internal organs, and to necrosis 
of bone. 

Prognosis. — Eecovery usually takes place in the course of a fortnight, 
although recurrences at intervals of a week or two frequently occur be- 
fore the health is fully restored. 

Treatment. — In the treatment of simple purpura the indications are 
to maintain the bodily health by rest and careful feeding, with nutritive, 
easily digested food at short intervals, to meet any vital depression which 
may occur by stimulants, and to use certain remedies because they have 
been used before, and, unless given in overdose, are incapable of harm. 
Among the more important of these standard remedies are ergotin, tinc- 
ture of ferric chloride, and dilute sulphuric acid. As stimulants may 
be employed quinine, strychnine, alcohol, and digitalis, according to the 
needs of the individual case. Although the symptoms so closely re- 
semble those of scurvy, lemon juice has no curative power. Arsenic in 
ascending doses has been strongly recommended by some recent writers. 

RHEUMATIC PURPURA. 

Definition. — A disease characterized by ecchymoses, various cuta- 
neous eruptions, inflamed joints, and rheumatic pains. It is also called 
peliosis rheumatica and Schoenleirf s disease. 

Symptoms. — It occurs offcenest among young male adults. Its onset is 
frequently sudden, indicated by moderate fever, loss of appetite, debility, 
occasional sore throat, and painful swelling of the large joints, especially 
of the lower extremities. In the course of a few days multiple cutaneous 
hemorrhages appear upon the lower extremities, then upon the upper, 
and finally on the abdomen or the chest. The hemorrhages are often 
associated with urticaria, erythematous nodules, or bulla}. The articular 
symptoms may disappear with the appearance of the eruption. Albu- 
minuria may occur. Relapses, perhaps several, are frequent, usually 
occurring in the course of a week or ten days, and recurrences may take 
place after a considerable interval of time. 

Diagnosis. — The diagnosis is based upon the presence of acute poly- 
arthritis, followed by cutaneous hemorrhages, with or without urticaria 
and osdema. It may be necessary to eliminate the symptomatic hemor- 
rhages occurring in acute infectious diseases, especially those complicated 
with joint- affections like acute articular rheumatism and scarlet fever. 
In rheumatic fever the articular affections precede by a considerable 
interval the hemorrhages which are due to acute endocarditis. In scar- 
let fever the hemorrhages are more general, and precede the affections of 
the joints. Scurvy may be simulated, since muscular and articular pains 
may be present in this affection, and the gums may be affected in rheu- 
matic purpura. But rheumatic purpura is an acute febrile disease from 



26 



GENERAL DISEASES. 



the outset, and lacks the preliminary cachexia and the dietetic etiology 
of scurvy. 

Prognosis. — The prognosis as to the individual attack is favorable, 
recovery usually occurring in the course of two or three weeks. The 
liability to relapses and recurrences has already been mentioned. 

Treatment. — In rheumatic purpura the general management of the 
case is that of simple purpura, but we have seen very remarkable and 
positive effects from the exhibition of salicylates, preferably of ammo- 
nium salicylate, which should at first be given until it produces distinct 
tinnitus aurium, and afterwards be administered in small doses. When 
there is a marked tendency to relapses the continuous use of the sali- 
cylates has been in our experience effective. A mixture of the ammo- 
nium and strontium salts is preferable. From time to time the adminis- 
tration of the drug should be interrupted, for fear of producing too much 
depression. 

HENOCH'S PURPURA. 

Of late attention has been called, especially by Henoch, to a severe 
type of rheumatic purpura in which the onset is often violent and the 
arthritis, cutaneous hemorrhages, eruptions, and oedema are associated 
with hemorrhages from the mucous membranes, abdominal pain, vomit- 
ing, and diarrhoea. In some cases the oedema is conspicuous, in others the 
hemorrhagic spots or erythematous nodules, and in still others the gastro- 
intestinal symptoms. In addition to an elevated temperature a splenic 
tumor is often found, and hemorrhagic nephritis has been observed in a 
number of reported cases. Eecurrences are frequent, and the disease may 
then be prolonged over a period of months. Quincke has called atten- 
tion to a circumscribed oedema called angioneurotic, which may be recur- 
rent and associated with effusions into the joints, hemorrhage from the mu- 
cous membranes, vomiting and colic, lasting for hours or days. It rarely 
presents the characteristics of an infectious disease. Osier suggests that 
rheumatic purpura and angioneurotic oedema may be closely related and 
due to a toxaBmia. 

PURPURA HEMORRHAGICA. 

Definition. — This affection, also called Werlhof's disease, or Morbus 
maculosus Werlhofii, is characterized by extensive hemorrhages into the 
skin and from the mucous membranes, associated with painful and 
swollen joints. 

Etiology. — Girls or young women are more likely to be affected, espe- 
cially those living under bad hygienic conditions. Its infectious origin is 
suggested by the simultaneous disease of mother and foetus, and by the 
experiments of Petrone, who produced multiple hemorrhages in rabbits 
by introducing blood from a diseased patient. Letzerich has found in 
three cases a bacillus, the inoculation of pure cultures of which produced 
symptoms resembling those of hemorrhagic nephritis. Kolb also has in- 



DISEASES OF THE BLOOD. 



27 



oculated animals with cultures of a bacillus found in fulminating pur- 
pura; with the production of purpuric spots and internal hemorrhages. 

Morbid Anatomy. — Hemorrhages may be found within the skin, 
the mucous and serous membranes, and more rarely within the serous 
cavities and in the joints. Enlargement of the spleen is frequent. 

Symptoms. — The progress of this affection resembles that of an acute 
infectious disease. After several days of loss of appetite, perhaps vom- 
iting, muscular pains, painful and swollen joints, and elevated tempera- 
ture, numerous multiple cutaneous hemorrhages occur, especially on the 
lower extremities, and tend to become confluent. Extensive hemorrhages 
also take place from the mucous membranes, particularly of the digestive 
and urinary tracts. Bronchial and pulmonary hemorrhages are rare. In 
the milder cases the patient may recover in the course of a fortnight, al- 
though recurrences are not infrequent, the disease then extending perhaps 
over a period of months. In the severer cases-^pwrpitra fulminans — death 
may occur in the course of twenty-four hours, or at a later period, from 
collapse or intracranial hemorrhage. In the latter series of cases there 
may be colic and diarrhoea with high fever and a typhoid state, and 
endocarditis and hemorrhagic nephritis may be found as complications. 
Apparently mild cases may become severe. 

Diagnosis. — Scurvy is to be differentiated by the usual restricted oc- 
currence, the absence of a preliminary cachexia and faulty diet, and the 
freedom of the gams from disease. Simple purpura is to be excluded 
by the severer symptoms and the occurrence of internal hemorrhages, 
while purpura rheumatica is to be differentiated by the absence of con- 
spicuous primary affections of the joints. The fulminating cases may 
be confounded with an apoplectiform hemorrhagic exanthem, especially 
hemorrhagic small-pox, and with cerebro-spinal meningitis. These affec- 
tions are to be excluded by the slight fever and the absence of epidemics. 

Treatment. — The treatment of purpura hemorrhagica is that of 
simple purpura, combined with the free administration of gallic acid, oil 
of erigeron, ergot, turpentine, aromatic sulphuric acid, and other of the 
internal hemostatics, whose control over the bleeding is, however, un- 
trustworthy. The subsequent anemia should be treated in the usual 
way with iron and tonics. 

H^EMOGLOBINiEMIA. 

A term applied to the presence of free hemoglobin in the blood. 
This condition is due to a variety of causes which result in the escape of 
hemoglobin from the red blood-corpuscles and its solution in the blood- 
serum. According to Ponfick' s researches in particular, such dissolved 
hemoglobin when in small quantity is disposed of by the spleen and 
liver. If the quantity set free is excessive the kidneys eliminate the 
excess and hemoglobinuria results. For the further consideration of this 
subject, see Hemoglobinuria. 



28 



GENERAL DISEASES. 



DISEASES OF THE SPLEEN. 

Although, the spleen plays an important part in disease, its alterations 
are usually secondary to disease elsewhere, and the associated symptoms 
are rather due to the primary affections than to accompanying modifica- 
tions in the function of this organ, the physiology of which is so little 
known. 

The physical exploration of the spleen is, however, of decided im- 
portance to the physician, enlargement of this organ being of frequent 
occurrence in a number of diseases, especially those due to an infection 
of the blood. The establishment of the diagnosis of typhoid fever, sep- 
ticemia of obscure origin, malaria, fibrous hepatitis, and amyloid degen- 
eration may be largely aided by the physical examination of the spleen. 
For this purpose percussion may be of but little importance, although an 
oval-shaped area of dulness due to the spleen is normally found between 
the ninth and eleventh left ribs. Gaseous distention of the stomach or 
colon, or fluid in the pleura, or solidification of the lung, however, may 
so modify the results of percussion as to prevent satisfactory recognition 
of the position of the spleen. Fortunately, the alterations of the spleen 
of diagnostic importance are those due to enlargement of this organ, any 
considerable degree of which is to be appreciated by palpation. It is to 
be remembered that the lower edge of a normal spleen may be felt when 
displaced in consequence of deformity of the chest or spine causing a 
permanent depression of the diaphragm. For examination, the patient 
should lie either on the back or on the right side with a slight back- 
ward inclination, preferably with the thighs flexed. In the former case 
the physician applies light but firm pressure with the finger-tips of both 
hands closely approximated upon the abdominal wall in the left hypo- 
chondrium from below upward. As the patient takes a long breath the 
edge of the enlarged spleen may be felt as it descends below the costal 
cartilages. If the patient is lying on the side, the physician should face 
the back of the patient and should press with the finger-tips of both 
hands against the abdominal wall in the left hypochondrium from below 
upward, or should apply pressure with the finger-tips of the right hand 
upon the abdominal wall from below upward, the left hand being firmly 
pressed against the lower ribs. As the patient draws slowly a long 
breath the edge of the enlarged spleen may be felt to strike against the 
fingers. 

Enlargement of the spleen may be either acute or chronic, the former 
rarely resulting in any great increase in the size of this organ, the latter 
giving rise to some of the largest abdominal tumors. Acute enlargement 
is usually occasioned by infection, although it may be due to congestion 
from injury or embolism, and palpation of the lower border of the spleen 
may offer important evidence concerning the existence of an infectious 
process. An acute splenic enlargement is always to be sought for in 



DISEASES OF THE DUCTLESS GLANDS. 



29 



malaria ; it is present towards the end of the first week in typhoid fever. 
The viscus is usually somewhat sensitive to palpation. The associated 
symptoms serve for the recognition of typhoidal enlargement of the 
spleen, while the symptoms or examination of the blood establish the 
diagnosis of malarial enlargement. In chronic enlargement the spleen 
is superficial, smooth, resistant, with a sharply defined lower edge and 
sometimes a lobulated border near the navel. It is to be distinguished 
from the kidney by its superficial position and the absence of an over- 
lying colon, while the mobility of an enlarged spleen on inspiration is 
greater than that of an enlarged kidney. Chronic enlargement of the 
spleen of moderate degree may result from malaria and from chronic 
passive congestion in fibrous hepatitis. The more extreme degrees of 
chronic enlargement are due to leukaemia and pseudo-leukaemia, while 
amyloid degeneration produces both the lesser and more considerable de- 
grees of enlargement. The leukemic enlargement of the spleen is to be 
differentiated from the pseudo-leuksemie hyperplasia by the examination 
of the blood. A diagnosis of amyloid infiltration of the spleen is to be 
made when the enlargement of this organ is associated with an enlarge- 
ment of the liver or with albuminuria, dropsy, and chronic diarrhoea in 
the sequence of chronic suppuration, especially of bones and joints, and 
in that of tuberculosis and syphilis. A congenital enlargement of the 
spleen without amyloid degeneration is important evidence of inherited 
syphilis. 

MOVABLE SPLEEN. WANDERING SPLEEN. SPLENOPTOSIS. 

Etiology. — Excessive mobility of the spleen occurs as the result of 
congenital or acquired conditions, the former being represented by an 
abnormally long ligament, the latter by sudden muscular violence, pro- 
tracted muscular strain, or increased size of the organ. Prolapse of the 
spleen, splenoptosis, at times is a part of the general splanchnoptosis, in 
which a prolapsed stomach, colon, liver, kidney, uterus, and ovaries may 
be conjoined. 

Symptoms. — There may be no disturbance resulting from a wandering 
spleen, or the patient may complain of a sensation of discomfort in the 
left side, perhaps associated with the feeling of a movable object in the 
abdomen. Pain in the left shoulder is at times complained of, and is 
explained by the communication between the splanchnic and pneumo- 
gastric nerves by means of the semilunar ganglion. The movable spleen 
may be found in the left iliac fossa or to the right of the navel, and has 
been confounded with a tumor of the kidney, uterus, or ovary. It is 
usually freely movable, its hilus directed upward, and it may be returned 
to the left hypochondrium, in which the normal area of splenic dulness 
is absent. The mobility of the spleen may be so great as to cause a 
twisting of its ligaments and vessels. Perisplenitis is then likely to arise, 
and is manifested by the symptoms of a localized peritonitis. Adhesions 



30 



GENERAL DISEASES. 



may thus be formed between the spleen and the stomach or intestine, and 
dilatation of the former or obstruction of the latter result. 

The twisting may be so considerable that enlargement or atrophy of 
the organ follows. In the former event the discomfort is aggravated, 
whereas the atrophy is likely to afford relief to the symptoms. In rare 
instances the twisting may be so extreme as to cause a complete detach- 
ment of the spleen. 

Treatment. — For treatment of malarial enlargement of the spleen, 
see page 212 ; other splenic enlargements are not amenable to any known 
medicinal or hygienic treatment. In great enlargement of the spleen, and 
in wandering spleen, an abdominal bandage is often of service. 

EMBOLISM AND ABSCESS OF THE SPLEEN. 

Embolism of the spleen is of frequent occurrence, and abscess of the 
spleen is usually a result of infectious embolism, although sometimes due 
to localized inflammation in such infectious diseases as typhoid and re- 
lapsing fever, septicaemia, pysemia, and cholera, or from the extension of 
an inflammatory process from the peritoneum, stomach, kidney, or lung. 
Bland embolism of the spleen follows the transfer of an embolus from 
the aorta or the left side of the heart, except in the rare cases when 
an embolus from a venous thrombus passes through an open foramen 
ovale from the right auricle into the arterial circulation. The diseases 
in which such embolism is likely to occur are chronic endaortitis, valvular 
endocarditis, and interstitial myocarditis. Hemorrhagic infarction and 
an eventual scar result. The quantity of spleen destroyed is chiefly de- 
termined by the size and number of the emboli. The embolus may be 
sufficiently large to obstruct the main splenic artery, in which case a 
consequent thrombosis of the splenic vein may extend into the portal 
vein, producing thrombosis of the latter. 

The occurrence of splenic embolism is to be suspected when a sudden 
attack of pain in the splenic region is associated with a chill and fol- 
lowed by enlargement of the organ in a person presenting the conditions 
favorable to arterial thrombosis, especially chronic valvular endocarditis. 
Although recovery from bland embolism of the spleen is the rule, the 
exception above stated may take place, and the patient die from hemor- 
rhagic infarction of the intestine and acute peritonitis dependent upon 
secondary thrombosis of the intestinal branches of the portal vein. 

If the embolus is infectious, as in malignant endocarditis, one or more 
abscesses of the spleen, tending to become confluent, follow the mechan- 
ical results of embolism. A similar result is seen in abscesses of the 
spleen from the other previously mentioned causes. The entire spleen 
may be transformed into a bag of pus, surrounded by an acute perisple- 
nitis. Perforation may result, with the production of a general perito- 
nitis, or the abscess may be evacuated into the stomach, the intestine, or 
the pelvis of the kidney ; the pus may also escape into the pericardium, 



DISEASES OF THE DUCTLESS GLANDS. 



31 



or through the diaphragm into the lungs, or through the abdominal 
wall. 

Abscess of the spleen can usually be recognized by the existence of 
constitutional disturbance indicative of pus-formation, such as recurring 
chills or fever, profuse sweating, diarrhoea, loss of flesh and strength, 
associated with localized pain, rapid increase in the size of the spleen, 
with marked tenderness, and in some cases audible or even palpable 
friction. 

The prognosis of abscess of the spleen is very serious, death fre- 
quently resulting from septicaemia even after the successful spontaneous 
or surgical evacuation of the pus. The aspirator should always be used, 
at least for diagnostic purposes, but, pus being found, we believe it better 
to open the abscess by free incision. It is necessary, however, in such 
cases to defer the operation until adhesions have been formed between 
the spleen and the abdominal walls. 

DISEASES OF THE THYROID GLAND. 

Until within the past few years any radical treatment of the diseases 
of the thyroid gland was almost exclusively the province of the surgeon. 
Inflammation was extremely rare, except as a secondary process during 
the progress of a goitre, and, although resolution might take place, the 
more frequent result was an abscess requiring the use of the knife. In 
like manner tumors of the thyroid, whether benignant or malignant, the 
latter including the rare malignant adenoma as well as the sarcoma and 
cancer, were regarded as surgical affections. The discovery by Murray 
of the marvellous effects of thyroid extract in myxcedema has led to its 
use in the treatment of other affections of the thyroid with conspicuous 
success in a number of cases. 

GOITRE. BRONCHOCELE. STRUMA. 

Definition. — A persistent enlargement of the thyroid gland. 

Etiology. — This disease is endemic in various parts of the world, 
particularly in mountainous regions. Osier and, more recently, Dock 
have called attention to its occurrence in the regions bordering upon the 
great lakes of North America, principally in Michigan and Canada. 
Munson finds that goitre exists among the North American Indians, 
among whom it is most prevalent in the southern part of Montana. 
According to him, its distribution follows the course of the Rocky Moun- 
tains, and is independent of high altitude, climate, or excess of calcium 
salts. Both cretinism and exophthalmic goitre are rare among these 
people. The immediate cause of goitre is unknown, although Yirchow 
concluded that it was likely to exist in the drinking-water. Heredity 
is sometimes conspicuous. Females are more often affected than males, 
and the disease usually first appears in young persons near the age of 



32 



GENERAL DISEASES. 



puberty. In goitrous regions domesticated animals may be affected, 
especially horses and dogs. 

Morbid Anatomy. — The disease begins as a local or general hyper- 
plasia, due to an excessive formation of the follicles : hence the term 
adenoma of the thyroid or hyperplastic or follicular goitre. The enlarge- 
ment of the gland may be chiefly composed of the new-formed follicles, 
although in some cases an excess of fibrous tissue > in others, of vascular 
tissue, is formed : hence fibrous and vascular forms of goitre. The hyper- 
plastic cells are prone to undergo a hyaline, gelatinous, or colloid degen- 
eration : thus cavities of various size arise within the tumor, filled with 
colloid material of greater or less density, — colloid goitre. By the absorp- 
tion of the walls intervening between such cavities cysts are formed, 
which are often numerous and large, containing chiefly liquid contents, 
and give rise to the term cystic goitre. Lime salts are often deposited 
in the connective tissue of the goitre, producing a calcification or ossifi- 
cation of the wall. The enlarged thyroid forms a tumor not infrequently 
of the size of the fist, and it has attained the size of a man's head. 

Symptoms.— The disturbances produced by the goitre result from 
pressure upon neighboring parts, and do not arise until the gland has 
attained a considerable size. A rapid growth of the tumor not infre- 
quently takes place, with a corresponding increase in the severity of the 
symptoms. Most important among these is dyspnoea from pressure upon 
the trachea. The larynx may also be compressed, with modification in 
the character of the voice and respiration. Pressure on the oesophagus 
may produce difficulty in swallowing, and pressure upon the veins, es- 
pecially when the growth of the thyroid extends beneath the sternum, 
has produced fatal thrombosis. Pressure upon the sympathetic nerve 
may cause a narrowed pupil. Patients with goitre sometimes suddenly 
die and no obvious cause of death is discovered ; such an event is usu- 
ally attributed to asphyxia from sudden compression of the trachea or 
paralysis of the vocal cords. 

Prognosis. — Goitres may rapidly disappear, especially in young 
persons, but only in the absence of calcification and cystic degeneration. 
They usually persist throughout the life of the patient. 

Treatment. — Fibrous, cystic, amyloid, colloid, and calcareous degen- 
erations of the thyroid gland are not amenable to any medical treatment, 
and therefore belong to the province of surgery. When degeneration has 
not supervened, the tumor frequently disappears spontaneously upon re- 
moval to a non-goitrous district, or it may yield to the internal adminis- 
tration of iodine, Lugol's solution, ten to twenty drops, three times a day 
(well diluted), aided by the free use of iodine ointment. Ergot has been 
recommended by numerous authorities, given internally in full doses. 
Simple and ferruginous tonics are sometimes of service. Bruns states 
that out of twelve cases he succeeded in curing nine with the thyroid 
extract. We have seen the remedy tried in one case with most happy 



DISEASES OF THE DUCTLESS GLANDS. 



33 



result. Upon old cases with continuing residence in the infected district 
medicines have no curative influence. 

EXOPHTHALMIC GOITRE. GRAVES'S DISEASE. BASEDOW'S 

DISEASE. 

Definition. — A disease especially manifested by disturbed circula- 
tion, protruding eyeballs, goitre, and muscular tremors. 

Etiology. — It is found more often in women than in men, usually 
in adult life, although it has been observed in the young and in those 
of advanced years. It usually occurs in persons of inherited sensitive 
nervous organization. The disease itself may be inherited, and it may 
be present in several members of a family. 

A practical distinction is to be drawn between the primary or essen- 
tial variety of exophthalmic goitre and the secondary variety, in which 
similar symptoms may occur in the course of simple goitre, pregnancy, 
or affections of the nose. Abortive or doubtful forms of exophthalmic 
goitre, u formes frustes," are usually regarded as representing mild varie- 
ties of this disease. 

Immediate causes in persons predisposed may be emotional excite- 
ment, prolonged mental or physical strain, or severe acute disease. 

Morbid Anatomy. — A variety of anatomical changes have been found 
in exophthalmic goitre, most of which are rather a result than a cause of 
the disease. Among these are hypertrophy and dilatation of the heart, 
inflammation of the endocardium and pericardium, and degeneration of 
the myocardium. Lesions of the sympathetic nervous system, as hyper- 
trophy or atrophy, sclerosis, and pigmentation, have been observed, but 
are not essential. The alterations present in the thyroid are those occur- 
ring in simple goitre, vascular dilatation being the most frequent. 

The conspicuous nature of the nervous symptoms has led numerous 
observers to regard this disease as a nervous affection, localized more par- 
ticularly in the sympathetic nervous system, either at its origin or in its 
course. Although local lesions are sometimes found, they are neither 
constant nor characteristic. The frequent mental and motor disturbances 
were attributed to lesions in various parts of the brain. If none were 
found, disturbances of circulation in the regions concerned were assumed 
as an explanation. At the present time the theory advanced in 1891 by 
Mobius prevails. According to this, the resulting disturbances are due to 
a toxaemia dependent upon a pathological activity of the thyroid gland. 
This view is based upon a comparison of the symptoms of exophthalmic 
goitre and those of myxoedema, in which affection there is atrophy of the 
thyroid and of cachexia strumipriva following extirpation of the thy- 
roid in man and animals. Certain of these symx^toms are antagonistic : 
e.g., in exophthalmic goitre there are acceleration of the pulse, profuse 
perspiration, and increased mental excitability, while in niyxcedema and 
cachexia strumipriva a slow pulse, dry skin, and sluggish mind occur. 

3 



34 



GENERAL DISEASES. 



Exophthalmic goitre and myxcedema may be present in the same family ; 
the latter may follow the former, or the two may concur in the same in- 
dividual. Goitre may he followed in the course of years by symptoms of 
exophthalmic goitre, and symptoms of exophthalmic goitre may rapidly 
follow extirpation of the diseased thyroid. Thyroid extracts in myx- 
oedema and in health produce some of the symptoms of exophthalmic 
goitre, and are not well borne in certain cases of the latter disease, 
although sometimes the goitre is diminished and the patient is im- 
proved. The theory that disease of the thyroid causes exophthalmic 
goitre is further favored by the relief to this disease which sometimes 
follows removal of the thyroid. 

Symptoms. — The symptoms of exophthalmic goitre are usually of 
slow and gradual development, but they may suddenly arise and rapidly 
progress. They are generally regarded as neuroses, — that is, as func- 
tional disturbances without obvious cause. A rapid pulse is one of the 
most constant symptoms. The average beat of the pulse may be upward 
of a hundred, and upon exertion or excitement its frequency may be 
nearly doubled. The patient complains of palpitation, and a tumult- 
uous throbbing of the heart, carotids, and abdominal aorta is visible. 
Murmurs may be heard over the heart and the large arteries, and there 
is accentuation of the valvular sounds. 

Protrusion of the eyeballs, exophthalmos, when present, usually fol- 
lows the circulatory disturbance. It is apparently due to the presence 
of an increased quantity of blood or lymph in the orbit, since it may 
take place suddenly, may vary at different times in the same individual, 
and disappears after death. It is sometimes so extreme that the lids can- 
not be closed. With the persistence of the disease increase of the orbital 
fat-tissue may take place, causing permanent protrusion of the eyeballs. 
Graefe discovered that in certain instances the upper lid remains im- 
movable instead of following the eye when it is turned downward, and 
Stellwag called attention to an increased separation of the eyelids due to 
retraction of the upper lid even when there is no protrusion of the eye- 
ball, while Mobius observed an inability of the eyes to converge upon an 
object in the immediate vicinity. The pupil is usually unaltered, and 
vision is undisturbed. Ulceration and opacity of the cornea sometimes 
take place from the unprotected condition of the eye or from a disturb- 
ance of its trophic nerves. 

The enlargement of the thyroid is essentially due to a dilatation of its 
blood-vessels, especially the arteries. It gradually increases in size, but 
may undergo sudden and rapid changes of volume when the patient suf- 
fers from attacks of palpitation. Follicular enlargement may also take 
place, and colloid degeneration and calcification may occur. The en- 
largement may be partial or total. There are often visible pulsation, a 
palpable thrill, and a double systolic murmur. Guttmann regards the 
presence of the last as characteristic of Graves's disease, not finding it in 



DISEASES OF THE DUCTLESS GLANDS. 



35 



simple goitre. The experience of Dock agrees with that of Guttmann, 
although Mannheim states that it was absent in fourteen out of thirty - 
seven cases. He admits the possibility that it may be present at some 
time in every case of exophthalmic goitre. 

Persons suffering from Graves's disease are usually neurasthenic or 
easily excited or depressed, and may become maniacal or melancholic. 
General muscular tremors, superficial, occurring every few seconds, are 
so constant as always to be sought for. Spasmodic movements of the 
muscles resembling those of chorea may take place, or epileptiform 
attacks occur, while muscular weakness, both general and local, is fre- 
quent, the inspiratory expansion of the chest even being diminished. 
Joffroy observed that the forehead failed to contract when the patient 
with head bent forward was told to look up without raising the head. 

The respiratory tract may be affected, as shown by a spasmodic cough 
and rapid breathing. The voice may be feeble. Yomiting and diar- 
rhoea, frequent micturition, increased quantity of urine, albuminuria, 
and glycosuria may be present, and disturbances of menstruation are 
frequent. There may be temporary febrile attacks. The skin flushes 
readily, and taches cerebrales, the red streaks produced by drawing the 
finger-nail over the skin, are easily induced. Sweating is frequent, and 
pigmentation, scleroderma, herpes, urticaria, and circumscribed or- gen- 
eral oedema are occasional symptoms. Charcot has observed a diminu- 
tion in the resistance of the skin to the galvanic current. There may be 
premature loss of hair and teeth, and the hair may early turn gray. 
Epistaxis, haemoptysis, and gastro-intestinal hemorrhages may occur. 
With the persistence of the symptoms the patient loses flesh and strength 
and becomes pale. 

Diagnosis. — In the presence of the three characteristic symptoms, 
namely, tachycardia, goitre, and exophthalmos, the diagnosis is easy. 
The goitre may be small or absent, and exophthalmos is usually of late 
development, although it may exist for years before the other symptoms 
arise. Tachycardia is the most constant symptom, and if persistent and 
accompanied by muscular tremor and a number of the symptoms above 
mentioned, the diagnosis may be made even in the absence of goitre 
and exophthalmos. Time may, therefore, be essential to the diagnosis, 
since a tachycardia may prove to be an early symptom of exophthalmic 
goitre, and a characteristic grouping of the symptoms may not appear 
until fifteen years after palpitation has existed. 

Prognosis. — Complete recovery from genuine exophthalmic goitre 
rarely takes place, although temporary improvement is not infrequent. 
The disease extends over a period of years, and death usually is due to 
some intercurrent disease, although it may result from rapidly developed 
acute mania or progressive emaciation and debility. The prognosis is 
more favorable in the secondary variety, in which enlargement of the 
thyroid has preceded other symptoms by a period of years, or in which 



36 



GENERAL DISEASES. 



the symptoms rapidly follow fright or occur in nasal affections and 
pregnancy. 

Treatment. — There is no known specific treatment directly curative 
of exophthalmic goitre. Preparations of the thyroid gland have been 
much administered, but in our experience, which finds corroboration in 
the printed records, they have distinctly aggravated the symptoms. We 
have seen spontaneous and permanent recovery occur during an acute 
splenitis ending in abscess, and have in three cases used glycerin extract 
of spleen (ten to twenty minims given hypodermically daily) with ap- 
parently marked benefit. Pronounced amelioration may often be obtained 
by change of climate ; in our experience high elevations have greatly 
aggravated the cardiac distress, and much benefit has been derived from 
a sea-shore residence. On the other hand, Oppenheim affirms that living 
in the Alps at an elevation of from three to five thousand feet in the 
earlier stages of the disease often produces a notable good effect. Pro- 
longed rest in bed, with massage, and a more or less strictly carried out 
rest-cure, are frequently of temporary service, and should from time to 
time be resorted to when the symptoms become severe. In the acute 
cases absolute rest in bed should be enforced. The application of Leiter's 
tubes or of an ice-bag over the heart or over the thyroid gland itself for 
half an hour to an hour at a time sometimes distinctly quiets the heart's 
action, but is not always even temporarily beneficial. The cardiac drugs 
have very little influence over the rapidity of the pulse. In robust cases 
with evident excess of cardiac power, aconite may be carefully tried, and 
occasionally brings relief. In failing heart digitalis and strophanthus are 
indicated, but are rarely effective : some authorities prefer strophanthus to 
digitalis. Belladonna given in ascending doses until it produces marked 
dryness of the mouth or even slight dilatation of the pupil sometimes 
gives relief. Extract of ergot in large doses is commended by some 
writers. Neither arsenic nor iodine has any distinct control over the 
disease. When ansemia exists, a non-astringent preparation of iron should 
be administered. 

Yery good results are alleged to have frequently followed the use of 
electricity in Graves's disease. Vigouroux especially recommends the 
faradic current applied by means of a broad anode to the back of the 
neck and a smaller cathode placed over the sympathetic ganglia in the 
front of the neck and afterwards shifted to the motor points of various 
muscles of the face and neck, and still later replaced by a large cathode 
placed over the heart region and the sternum, a very strong current 
being used to the sympathetics, a weaker one to the heart region. Most 
authorities, however, prefer the galvanic treatment, the usual plan being 
to put the cathode just behind the angle of the jaw with the anode over 
the heart or upper sternum. It is probable that the direction of the cur- 
rent makes little difference : thus, Osier directs that the cathode should 
be placed at the back of the neck and the anode over the heart, whilst 



DISEASES OF THE DUCTLESS GLANDS. 



37 



Erb states that the anode should be placed upon the cervical spine and 
the cathode upon the peripheral nerves. If direction makes any differ- 
ence, it is probably better to send the current down the nerve. The 
current should be of such strength as to produce slight pain. There 
can be no doubt that the heart is often immediately slowed, probably by 
irritation of the pneumogastric nerve, but it is very doubtful whether 
the electrical treatment of Graves's disease is ever effective. The seances 
must be carried over months, and any changes which occur in the course 
of the disease are probably due to psychical impression, or to other 
measures instituted, or represent the apparently spontaneous remissions 
of the disease which occur from time to time. 

Graves's disease has been treated surgically by electrolysis with as- 
serted advantage, and also by ligation of the thyroid arteries and by 
excision of the thyroid gland, which must be partial, otherwise myx- 
cedeina will result. According to Osier, "out of sixty-eight operations 
on record, eighteen completely recovered ; in twenty-six there was more 
or less improvement ; nine showed no change ; in five death was almost 
immediate, and in four death occurred within twenty-four hours." 

Under the name of exothyroipexia Jaboulay has introduced a new 
operation : an incision having been made in the median line, the gland 
separated from the trachea is left covered simply by an antiseptic dress- 
ing. It is said to decrease rapidly in size, and when the norm has been 
reached the wound is closed. 

MYXCEDEMA. 

Definition. — A disease especially characterized by an infiltration of 
the connective tissue, especially beneath the skin, with a gelatinous sub- 
stance, by mental sluggishness, and by atrophy of the thyroid gland. 

It has long been known that there is an intimate relation between 
alterations of the thyroid gland and cretinism. The latter affection 
occurs in regions in which goitre prevails, and if the children of families 
removing into such regions were goitrous, those born after such removal 
became cretins. It has, therefore, been considered probable that a com- 
mon etiological factor exists in goitre and cretinism, both of which con- 
ditions may be combined. Endemic cretinism results in a stunting of 
the body and a blunting of the intellect, each varying considerably in 
degree. In congenital or sporadic cretinism these alterations are still 
more conspicuous. The body is dwarfed. The subcutaneous tissue is 
exuberant, and many of the mental and physical characteristics re- 
semble those to be found in myxcedema. The thyroid gland is atro- 
phied, or absent in some cases. This condition is now generally con- 
sidered as a congenital variety of myxcedema. 

In 1873 Sir William Gull reported a series of cases of myxoedema 
under the title "On a Cretinoid State supervening in Adult Life in 
Women." A condition was described with resemblances to and differ- 



38 



GENERAL DISEASES. 



ences from cretinism. A few years later Ord published the appearances 
found after death, and introduced the explanatory term myxoedema. It 
soon became evident that atrophy of the thyroid gland was present, and 
importance was attached to this fact. It was then found, especially by 
Kocher and Beverdin, that total extirpation of the thyroid gland in the 
treatment of goitre, especially in young persons, resulted in the produc- 
tion of mental and physical debility, progressive anaemia, and swelling 
of the subcutaneous tissue. To this condition the term cachexia strumi- 
priva was applied. Horsley observed that a similar condition resulted 
fro in the removal of the thyroid in the lower animals. 

Myxoedema is thus to be distinguished from sporadic cretinism and 
cachexia strumipriva in virtue of its occurrence independently of the 
above-mentioned causes. 

Etiology. — This affection exists much more often in women than in 
men, rarely in children, except as sporadic cretinism. It may occur in 
several members of a family. It may follow or concur with goitre, and 
exophthalmic goitre and myxoedema may be present in members of the 
same family, even in the same individual. 

Morbid Anatomy. — The subcutaneous fat is diminished or increased, 
and is often replaced by a gelatinous material which becomes opaque on 
the addition of acetic acid. The fat-tissue elsewhere in the body may be 
increased. The thyroid gland is atrophied or absent, and the paren- 
chymatous portion may be atrophied, although the gland is enlarged. 
The pituitary body has been found increased in size in a number of 
cases of myxoedema, as well as in cretinism. 

Symptoms. — There is bloating especially of the face and neck, per- 
haps of other parts of the body, and supraclavicular swellings are fre- 
quent. The skin does not pit on pressure, and the bloating is evidently 
due to an increase in the volume and density of the subcutaneous tissue, 
to which the skin is not intimately adherent as in scleroderma. In con- 
sequence of this condition the physiognomy is altered. The face is 
broadened ; the lineaments and wrinkles are obliterated ; the lips are 
thickened and everted ; the tongue may become enormously enlarged, 
interfering even with the swallowing of saliva, which may flow from the 
mouth, and tumors may form beneath the lower jaw from infiltration of 
the submaxillary glands. The face presents a pale, mask-like appear- 
ance suggesting that of a chalked clown, although a reddish patch may 
appear on the cheeks. The skin, especially of the hands, is coarsely 
wrinkled, dry, rough, and scaly, and of a brownish tint. The nails are 
frequently atrophied and brittle. The hair becomes coarse and dry, and 
premature loss of hair and teeth often occurs. 

Mental symptoms are also striking. The patient becomes phlegmatic, 
dull or stupid, loses interest in her surroundings, and is slow of speech. 
Memory fails. Hallucinations, especially of sight, are frequent, and the 
tendency is towards dementia. Numbness and neuralgic pains are often 



DISEASES OF THE DUCTLESS GLANDS. 



39 



early symptoms, and muscular weakness is complained of. The patellar 
reflex may be diminished. The pulse is slow, the temperature is sub- 
normal, and the hands and feet are cold. Leukocytosis has been found, 
and hemorrhages from the mucous membranes sometimes take place. 
Albuminuria is frequent, and casts may be present. Glycosuria is some- 
times observed, and in a case recently under observation we found an 
almost pure albumosuria, the precipitation with nitric acid resembling 
that caused by one-half per cent, of serum albumin. The disease is 
usually slowly progressive, extending over a period of years, but Osier 
reports a case regarded as myxcedema in which, although there was 
enlargement of the thyroid, the bloating of the face gradually disap- 
peared after persisting three or four months. 

Diagnosis. — The appearance of the patient is suggestive of a dropsy, 
but the skin does not pit on pressure. The expressionless face, the pecu- 
liar hands, and the mental sluggishness are sufficiently characteristic. 
Albuminuria and casts are temporary, and therefore do not indicate a 
chronic nephritis. 

Prognosis. — The prognosis is favorable, the symptoms rarely disap- 
pearing spontaneously, although amenable to treatment. In advanced 
cases death usually results from some complicating disease, especially 
tuberculosis. Starr suggests that among the cases in insane asylums 
regarded as chronic dementia there may be found some of curable 
myxoedema. 

Treatment. — The hygienic treatment of myxoedema consists chiefly 
in protecting the patient from cold. The drug treatment is practically 
ineffective, though arsenic, iron, and strychnine have been largely used, 
On the other hand, the most beneficial results follow the use of the 
thyroid gland, which probably acts by yielding to the system some 
principle necessary for the general nutrition. It is evident that the 
remedy cannot produce a permanent cure : hence the treatment by it 
is naturally divided into a first period, in which the gland or its prepa- 
ration is given in as large doses as can be borne until apparent cure 
is obtained, and a second period, in which the administration of small 
doses is continued through months or years in order to maintain the 
normal metabolism. The gland was formerly used finely minced, raw 
or very slightly broiled, — from a quarter to half of a gland taken from 
the sheep being daily administered. Experience, however, has shown 
that a glycerin extract, or the dried and powdered gland administered 
in tablets or capsules, is thoroughly efficient. It is better to begin with 
a very small dose (one grain of the dried gland three times a day) and 
steadily increase it until fifteen to twenty grains a day are taken or 
symptoms of the so-called thyroidism are produced : these are nervous 
disturbance, shortness of breath, great restlessness, delirium, rapid 
pulse, and excessive irritation of the skin. The evidences of ameliora- 
tion are rapid loss of weight and recovery of the natural perspiration, 



40 



GENERAL DISEASES. 



increase of urine, elevation of the bodily temperature and of the pulse- 
rate, and lessening of the mental torpor. In a few cases symptoms like 
those of Graves's disease have followed the over-administration of the 
extract. The symptoms of thyroidism almost invariably subside with 
the cessation of the administration of the gland. 

Cretinism, which may be looked upon as a form of congenital inyx- 
cedema, in its early stages is also amenable to the thyroid therapy. 

TUMORS OF THE THYROID. 

Other tumors of the thyroid than those occurring as goitre are rare, 
although sarcoma is sometimes to be found. The possibility that the 
adenoma of the thyroid is sometimes malignant, essentially a cancer, is 
suggested by the occurrence in various parts of the body of tumors with 
a structure resembling that of the thyroid gland. Such a generalization 
may be regarded as an exaggeration of what is more frequently observed, 
— namely, misplaced accessory thyroids, which may be found in the neck, 
in the anterior mediastinum, or at the base of the tongue, as reported by 
J. Collins Warren. Such accessory thyroids may form tumors of con- 
siderable size presenting the structural and degenerative peculiarities of 
goitre. 

The thyroid, whether goitrous or not, may be the seat of an abscess, 
and may contain tubercles or gummata. 

DISEASES OF THE THYMUS GLAND. 

Considerable pathological importance in former times was attached 
to diseases of the thymus gland, especially in infants, in whom it varies 
considerably in size and reaches its maximum development at the age of 
two years. It remains relatively unaltered from that time until the age 
of puberty, when it begins to shrink, and in the adult traces of it are 
found with difficulty. Spasm of the glottis in infants has been supposed 
to be the result of an enlargement of the thymus, and was formerly 
regarded as a thymic asthma, a view which is now generally rejected, since 
this symptom is usually absent when the thymus is enlarged. Jacobi, 
however, although maintaining that most cases of spasm of the glottis 
are due to central nervous changes, feels justified in assuming that fatal 
cases of laryngismus stridulus or spasm of the glottis may be owing to 
enlargement of the thymus gland. 

Minute hemorrhages are not infrequent in infants dying of suffocative 
diseases and in those suffering from a hemorrhagic diathesis. 

Abscesses are rare, if the cases of probable softened tubercles and 
gummata reported as abscesses are excluded. 

TUMORS OF THE THYMUS GLAND. 

Most important of the alterations affecting the thymus gland are 
tumors, which form the large majority of tumors of the anterior medias- 
tinum. To such tumors the term sarcoma or lympho- sarcoma is often 



DISEASES OF THE DUCTLESS GLANDS. 



41 



applied, although the term to be preferred is lymphoma. The thymus 
alone may be the seat of the lymphoma, or similar tumors may be found 
in remote parts of the body as well as within or near the thymus gland. 
In such eases of multiple lymphomata the condition is one of leukaemia 
or pseudo-leukaemia, the thymus being affected as part of the process. 
Lymphoma of the thymus in contrast to lymphoma of the mediastinal 
lymph-glands forms a homogeneous instead of a conglomerate tumor. 
The symptoms resulting from tumors of the thymus are those common to 
other mediastinal tumors, and will be mentioned in the section on Tumors 
of the Mediastinum. 

DISEASES OF THE ADRENAL GLANDS. 

Although anatomical changes in the adrenal glands are not infre- 
quently found at post-mortem examinations, they are usually insufficient 
to be associated with any characteristic symptoms. Amyloid degenera- 
tion and variations in the quantity of fat and pigment are encountered. 
Extensive hemorrhage may be found without its presence being sus- 
pected, and bland or malignant tumors occur. The significance of the 
transplantation of accessory adrenals in the capsule of the kidney will 
be mentioned in the consideration of tumors of that organ. Of greatest 
clinical importance are the cheesy alterations forming the most frequent 
lesions found in Addison's disease. 

ADDISON'S DISEASE. SUPRARENAL MELASMA. 

Definition. — An affection characterized by disturbances of diges- 
tion, extreme debility, and pigmentation of the skin, and usually asso- 
ciated with chronic tuberculosis of the adrenal glands. 

Etiology. — Males are three times as often affected as females. The 
disease generally occurs in adult life, and has been found rarely in chil- 
dren. It prevails among the poorer classes, and may be secondary to 
tuberculosis elsewhere. 

Morbid Anatomy. — Although some alteration of the adrenal glands 
is usually found, they may be free from any appreciable changes. The 
changes generally observed affect each gland, and consist in enlargement 
and induration due to a fibrous and cheesy transformation, the result of 
tuberculosis. The centre of the diseased portion consists of a cheesy 
material, either dry and hard or moist and soft, perhaps infiltrated with 
lime salts, while the periphery forms a fibrous capsule in which and in 
the vicinity of which miliary tubercles may be seen. Tubercle-bacilli 
have repeatedly been found in the diseased capsule. The symptoms of 
Addison's disease have also been present when signs of tuberculosis were 
absent. In such cases malignant disease or hemorrhage, amyloid degen- 
eration, sclerosis, or gummata of the suprarenal capsules have existed. 
In rare instances no disease of the adrenal gland is present. 

From the frequency with which degenerative and inflammatory changes 



42 



GENERAL DISEASES. 



of the solar plexus have been associated with disease of the capsules, it has 
been thought that disease of the sympathetic nervous system is the cause 
of the symptoms and may explain the occurrence of cases in which the 
adrenal glands were unaffected. In opposition to this view, however, is 
the fact that in Addison's disease the adrenal glands are more often dis- 
eased than is the solar plexus, and the latter structure is only occasionally 
abnormal in Addison's disease, and may show alterations like those which 
have been found in Addison's disease without there having been any 
symptoms of that affection. The alterations to be found elsewhere, with 
the exception of pigmentation of the skin, are largely attributable to the 
anaemia or intestinal disturbance symptomatic or characteristic of the 
disease, the former including the splenic swelling and red marrow, the 
latter the hyperplastic follicles of the intestine and the enlarged mesen- 
teric glands. Although the anatomical appearances indicate an intimate 
relation between Addison's disease and alterations of the adrenals, ex- 
perimental investigation has thrown no light upon this view. The same 
obscurity has followed experiments upon the abdominal sympathetic 
with the thought of determining the etiological importance of lesions of 
the semilunar plexus. At present it is recognized that in Addison's dis- 
ease the suprarenal capsules are far more often diseased than the semi- 
lunar ganglion, but in rare cases the symptoms of this disease may occur 
without anatomical changes in either of these structures. 

Symptoms. — Although pigmentation of the skin is the essential symp- 
tom in diagnosis, its presence is usually preceded by gradually increasing 
digestive disturbances and debility. The former are characterized by 
loss of appetite, nausea, vomiting, a sense of weight in the epigastrium, 
and frequent and obstinate diarrhoea. Pain, at times severe, may be 
complained of, and is usually referred either to the epigastrium or to the 
lumbar region, and the latter may be sensitive to deep palpation. The 
debility is out of all proportion to the digestive disturbances. The patient 
may be unable to walk, and becomes confined to the bed. Headache, 
vertigo, and attacks of fainting may occur, while still later convulsions, 
delirium, and coma shortly precede death. 

The pulse is quickened and feeble. Respiration is not especially af- 
fected, and fever is absent. Examination of the blood has shown no ma- 
terial changes of any constancy. The urine also presents no characteristic 
changes, although indican has been found increased in a certain number 
of cases, and albuminuria may be present towards the end of life. 

Pigmentation of the skin may be an early or a late symptom, although 
it is usually the first to call attention to the nature of the disease. The 
color varies between a pale lemon-yellow and a dark brown suggesting 
bronze. It is most abundant in those parts which are exposed to the 
light, as the face and the back of the hands, and is later conspicuous 
in the axillse, the bend of the elbow, and the groins. Circumscribed 
patches of pigment of various size may also be found both in the skin 



DISEASES OF THE DUCTLESS GLANDS. 



43 



and in the mucous membrane of the mouth, especially of the cheeks. 
The conjunctive and sclerotics are usually free from pigmentation, and 
are hence strongly contrasted with the pigmented skin. The pigment is 
deposited in the deeper layers of the rete Malpighii, and apparently 
represents an excess of that normally found in this region. 

Diagnosis. — The diagnosis essentially depends upon the association 
of pigmentation of the skin with extreme debility. It is therefore im- 
portant to exclude other causes of pigmentation of the skin, as jaun- 
dice, exposure to the sun, racial characteristics, and cutaneous disease. 
Especial importance in differential diagnosis is to be attached to the 
peculiar distribution of the pigment, particularly to its presence in the 
mucous membrane of the mouth. It is difficult, perhaps impossible, to 
diagnosticate cases of suprarenal disease in which the debility is present, 
but the discoloration of the skin is either slight or doubtful. 

Prognosis. — Addison's disease usually terminates fatally in the course 
of two years, although temporary periods of improvement may occur. 
It may prove fatal in the course of a few weeks, and, more rarely, may 
persist throughout a period of ten years. In the past the reported cases 
of recovery have been so exceptional as to suggest an error of diagnosis ; 
how far the new treatment will avail the future will show. 

Treatment. — There is no specific drug treatment for Addison's dis- 
ease. Eest in bed, iron, strychnine, and various tonics, the meeting of 
symptoms as they arise, careful feeding, with an easily digested nutri- 
tious diet, and the occasional use of the milk-cure, constitute the ordi- 
nary means for protracting a hopeless battle. We have seen in ap- 
parently typical, very advanced Addison's disease recovery follow the 
hypodermic use (ten to fifteen minims a day) of the glycerin extract of 
the suprarenal capsules of beef, fifteen minims representing ten grains 
of the capsules. 

Other cases have been reported of similar benefit from the adminis- 
tration by the mouth of the raw or dried gland. Failures have also been 
recorded, but at present writing the evidence is sufficient to demand thor- 
ough trial of the method in every case. Failure is to be expected in 
some cases, on account of the malignant nature of the local disease ; thus, 
adrenal tuberculosis might become the starting-point of a wider infection. 
The dose and the best method of exhibiting are not yet known j two 
uncooked adrenals of the sheep may be eaten in a day, or probably 
about half a gland from a steer, or five grains of the dried gland may 
be administered three times a day in capsules. In any case the amount 
taken should be increased until a marked amelioration is obtained, some 
disagreeable symptoms are produced, or established failure has been 
reached. The glands should always be procured by a veterinarian, to 
prevent mistake. 



44 



GENERAL DISEASES. 



CHAPTER II. 

LOCOMOTOR AND CONSTITUTIONAL DISEASES. 
MYOSITIS. 

Definition. — Inflammation of the muscles. 

Bheumatic myositis is discussed under the head of muscular rheuma- 
tism (page 74). 

A suppurative myositis is not rare in pyaemia, and occasionally follows 
influenza, typhoid fever, and other infectious diseases. It is to "be 
treated by local blood-letting, continuous application of cold, and other 
antiphlogistic methods. 

Under the name of myositis ossificans progressiva has been described a 
rare disease, in which either in localized spots or in wide- spread areas the 
muscle-tissues undergo ossification. This disease, which occurs chiefly 
in men, commences with swelling, tenderness, and other indications of 
inflammation. After these have subsided the muscle remains hard and 
resistant, and gradually undergoes conversion into a bone-like tissue. 
The calcification seems to be especially abundant in the neighborhood of 
the attachment of the muscles ; but the whole muscle may be converted 
into a bony plate. The heart muscle may be affected. Concerning the 
etiology of myositis ossificans we have no knowledge ; the course of the 
disease is extremely slow, and is not modified by treatment. 

ACUTE POLYMYOSITIS. PRIMARY MYOSITIS. 

Definition. — An acute inflammation which attacks most or even all 
of the muscles of the body. 

Etiology.- — The cause of polymyositis is unknown ; it may be some 
specific germ or poison. 

Morbid Anatomy. — In polymyositis there seems to be a true inflam- 
mation of the muscles, involving both the muscular fibres and the inter- 
stitial connective tissue, with congestion, exudation of leukocytes about 
the vessels, softening, and finally destruction. Hepp reports in his case 
that the intramuscular fibrous tissue was scarcely involved, and that the 
muscle-fibres were in a condition of hyaline degeneration. The periph- 
eral nerves have been found to be perfectly normal. All the voluntary 
muscles of the body are attacked. 

Symptomatology. — Without apparent cause the subject of polymyo- 
sitis, who is usually a young or middle-aged person, begins to suffer with 
pains in the arms, legs, and trunk, associated with more or less tender- 
ness on pressure, and soon followed by loss of motor power. Fever, if it 
come not on at once, soon appears, and a marked cedematous swelling 
occurs, beginning in the extensor side of the extremities and spreading 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



45 



until it involves the whole body, even to the face. The oedematons swell- 
ing may be very great and the parts stiff. Enlargement of the spleen 
appears to be a universal symptom. In many cases there is a peculiar 
erythematous rash irregularly scattered over the trunk and extremities, 
leaving behind it distinct pigmentation. 

As the disease progresses, the muscles of deglutition and of respiration 
become affected, producing great difficulty in swallowing and severe 
dyspnoea. Bronchitis and lobular pneumonia are soon developed, with 
a peculiar distressing inability to expectorate. In the recorded cases 
death has usually occurred within a few weeks, from paralysis of respira- 
tion. In some instances, however, life has been prolonged for two or 
more years, during which time there has been atrophy of some of the 
affected muscles. Whether or not there are mild cases of polymyositis 
ending in recovery seems at present somewhat doubtful. 

Diagnosis. — Polymyositis is distinguished from multiple neuritis by 
the pronounced oedema. It may be indistinguishable from trichinosis 
save by an examination of a piece of the affected muscle or by a know- 
ledge of the etiology of the disorder. 

Treatment. — Experience with polymyositis has been so limited that 
no settled opinion can be arrived at concerning the best method of treat- 
ment. It is probable that the direct action of medication will be found 
very slight, and that the only treatment will be one of stimulation and 
support, such as is adopted in cases of low fevers. 

PRIMARY MYOPATHY. 

Definition. — A chronic degenerative disease of the muscles with 
atrophic loss of fibre, not dependent upon any affection of the nervous 
system. 

Pseudo-muscular hypertrophy and the various atrophic muscular dis- 
eases were considered as representing several distinct affections until the 
researches of Erb showed that anatomically as well as clinically the gra- 
dations between the various types are so complete that these should be 
considered as one disease. It is hardly necessary here to describe all 
the varieties of the disorder, but some of the more remarkable and con- 
sistent forms will be separately discussed in the section on symptoma- 
tology under the grouping of the pseudo-hypertrophic form, in which 
enlargement of the affected muscles predominates, and the atrophic 
forms, in which atrophy is more apparent than is enlargement. 

Etiology. — The causes of primary myopathy are unknown. The 
disease usually begins during childhood, but may come on in early youth, 
and in extremely exceptional cases as late as forty years of age. It is 
probably due to some original vice of constitution, especially as it is not 
rarely a family affection recurring through several generations. 

Morbid Anatomy. — The essential lesions are exclusively in the mus- 
cles. They consist of atrophy and hypertrophy of the primitive muscle- 



46 



GENERAL DISEASES. 



fibres, increase of the muscle-nuclei, growth of the sheaths of the muscle- 
fibres and bundles with deposition of fat in them, and final destruction 
of the muscle-fibres, with vacuolation and fatty degeneration. Erb be- 
lieves that the primary change is the hypertrophy of the fibre. 

Sacara-Tulbure noted in one case enlargement of the lymphatics, with 
dilatation of the lymphatic vessels and sclerosis of the arteries all over 
the body, and a peculiar hyaline degeneration of the walls in many 
parts. There have also been found various alterations in the nerves and 
nerve-centres ; but these differ so much as to have no significance, and 
have been altogether wanting in various cases. If there were any doubt 
as to the correctness of the teaching of Charcot that the disease is an 
essential myopathy, it has been set aside by Babinski and Onanoff, who 
have shown that the disease in its development follows the embryological 
muscular territories. 

Pseudo- Hypertrophic Myopathy. 

Symptomatology. — The onset of pseudo-hypertrophic paralysis may 
be so insidious that the disease may have existed for years before atten- 
tion is called to the disorders of position and gait. In the fully-formed 
disease these are characteristic. In standing the feet are wide apart, 
whilst the belly is thrust far forward and the shoulders far backward, 
producing an excessive lordosis, which is chiefly due to the weakness 
of the muscles of the back, and persists in the sitting posture unless sup- 
port to the back be afforded. In walking the child preserves its bal- 
ance with difficulty, tripping and falling over the slightest obstacle ; the 
gait is waddling, the pelvis rising and falling much more than is normal. 
Owing to the weakness of the muscles of the back and of those going 
from the pelvis to the thigh and from the thigh to the lower leg, the child 
in rising out of a chair helps himself with the hands upon the thigh or 
the knee. Getting up from the floor is a laborious task, which is accom- 
plished by first rolling over on the face, then elevating the rump, then 
getting on the knees, then raising the knees from the ground with the 
help of the hands and feet, then placing one hand upon the knee com- 
mencing the elevation of the back, and then using both hands climbing 
up the legs, so to speak. (See Fig. 1.) In bad cases it may be impossi- 
ble for the subject to rise from the horizontal position without assistance 
from some external support. 

Owing to the weakness of the shoulder muscles, the shoulder-blades 
fail to yield a fixed support to the arm in its movements, and even when 
quiet have their inner margins thrown out in projections almost like 
wings. An examination of the stripped child will show in most cases 
great enlargement of the affected muscles. With this enlargement there 
are frequently prominence and hardness, but the muscles lack the well- 
known outlines present in persons with highly developed normal mus- 
cles, the limbs being rounded and the outlines flowing and regular, 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



47 



somewhat as is seen in stuffed animals. In many cases muscular atrophy 
and hypertrophy coexist. The affected limbs are apt to be very cold. 

The muscles most prone to suffer are the cucullaris, the greater ser- 
ratus anticus, the sterno- costal portion of the pectoralis major, the latissi- 
mus dor si, the rhomboid, infra- spinatus, and deltoid, the biceps, brachialis 
internus, and long supinator, the erector muscles of the back, the glutsei, 
the quadriceps femoris, the adductors, the calf- muscles, and some of the 
peroneus group. 

Fig. 1. 




Diagram showing the method of getting up off the floor in pseudo-hypertrophic paralysis, beginning 

with No. 1. 



Fibrillary contractions in the affected muscles may be pronounced, 
and various French authors state that there is a period of excessive 
muscular irritability. Nevertheless, as the cases ordinarily come under 
observation, the patellar and other reflexes are diminished or lost, and 
the mechanical excitability of the muscles is lowered. The electrical 
reaction gradually weakens as the muscles disappear in atrophy, but 
never undergo qualitative changes, the reaction of degeneration never 
appearing. According to Legros and Onimus, a pronounced susceptibility 
to loss of electrical excitability under the continuous use of the faradic 
current is characteristic of the disease. 

Late in the disease contractures appear and produce various deform- 
ities. Arthropathies and other trophic changes have been noted so in- 
frequently that they must be looked upon as accidents and not as features 
of the disease. Disturbances of sensibility are rarely pronounced, but 
more or less complete ansesthesias of sensibility or of special senses may 
exist. 

The thyroid gland is often abnormally developed, and various anoma- 
lies of the genital organs have been recorded. Sacara-Tulbure asserts 
that the skull of the child is usually peculiar, and that the teeth are 



48 



GENERAL DISEASES. 



nearly always striated, denticulated along their free borders, irregular, 
often imbricated, and frequently excessive in number. 

Atrophic Myopathy. 

From time to time there have been described various forms of pro- 
gressive muscular atrophies, all of which essentially belong to primary 
myopathies, differing from the pseudo -hypertrophic variety only in the 
failure to deposit inert matter in the muscle whose true structure is under- 
going atrophy. As a rule, it is in this class of cases that the evidences of 
distinct heredity are most pronounced. It is not necessary here to describe 
more than two types of the atrophic forms of primary myopathy, although 
in rare cases the localization of the attack varies almost indefinitely. 

Type 1. — Scapulohumeral ; juvenile form of Erb. — In this type of my- 
opathy the affection usually commences at about the twentieth year, and 
involves the muscles of the upper arm and shoulder and of the buttocks 
and thighs. The deltoid muscle is often spared. The calf-muscles are 
frequently attacked, but undergo pseudo -hypertrophy, so that they may be 
firm and hard whilst all the other muscles are wasted. The face-muscles 
are not affected. 

Type 2. — Facioscapulohumeral type of Landouzy and Bejerine ; the in- 
fantile form of Duchenne. — This affection usually commences in infancy, 
but may be delayed until puberty ; it appears first in the face, especially 
in the orbicular muscle of the mouth, from which it spreads until all the 
muscles of the face are symmetrically involved. In this way is produced 
a very peculiar physiognomy, the myopathic face. In repose the face is 
serious, immovable, usually with a somewhat apathetic expression of 
chagrin. The lips are protuberant, thick, and everted ; the eyes cannot 
be closed, and in some cases the mouth cannot be shut. Under emo- 
tional excitement the face is, as it were, in a mask ; movements are im- 
possible or exceedingly slow. Whistling or any other act that requires 
closing of the lips is impossible. After a time the muscles of the 
shoulder and upper arm are invaded, and in some cases the muscles of the 
hands finally undergo atrophy. Indeed, the disease may affect the mus- 
cles of the lower extremities and the back ; and cases have been reported 
in which the diaphragm, the intercostal muscles, and the abdominal 
muscles have participated. As there is little tendency in this type to 
enlargement of the muscles, the case may finally put on the aspect of a 
wide-spread progressive muscular atrophy. 

Diagnosis. — The diagnosis of pseudo-muscular hypertrophy is usu- 
ally very easy. In certain cases, however, of the atrophic form it may be 
difficult to distinguish between the affection and progressive muscular 
atrophy. Typical progressive muscular atrophy comes on late in life, 
and begins in the muscles of the hands, whilst primary myopathy de- 
velops early, and begins in the muscles of the face, the shoulder-girdle, 
the calves, or the thighs. 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



49 



Treatment. — There is no known treatment that has any effect upon 
the degeneration of the muscles. Gymnastic training and all forms of 
muscular exercise do harm rather than good. Massage and electricity 
have no distinct effect on the muscles. 

THOMSEN'S DISEASE. CONGENITAL MYOTONIA. 

Definition. — An hereditary affection, characterized by the occur- 
rence of tonic cramps in the muscles on the attempted performance of 
voluntary acts. 

Etiology. — Nothing is known as to the causes of this affection, ex- 
cept that it is a family disease, appearing in groups of cases in successive 
generations. 

Morbid Anatomy. — The only knowledge that we have as to the 
pathology of this disease has been obtained by examination of exsected 
pieces of muscle. These show great hypertrophy of the primitive bun- 
dles, with an increase of the nuclei of the sarcolemma of the interstitial 
tissue. 

Symptomatology. — This disease may develop in early childhood, but 
more frequently comes on about the time of puberty. The muscles are 
usually over- developed in size, but with less than the normal contractile 
power, often seemingly stiff and awkward in movement. The charac- 
teristic symptom of the disease is that when a group of muscles which 
have been long quiet are brought into action the voluntary movement 
is arrested by a tonic muscular contraction which lasts from five to thirty 
seconds and then relaxing permits the motion until the spasm recurs. 
When the voluntary action is persisted in, the tonic contractions be- 
come less and less, and soon disappear, so that the subject can continue 
movements unembarrassed. The tonic contractions are especially severe 
when the originating voluntary movement is sudden and energetic ; they 
are usually manifested in nearly all the muscles of the body, but in some 
cases are confined to certain groups. The muscles of the eye and of 
respiration are very rarely affected ; the tongue is often implicated. The 
contractions are increased by exposure to cold, by excitement, and by the 
nervousness caused by being watched ; they are diminished by warmth, 
by mental quiet, and by free alcoholic potations. 

The mechanical excitability of the muscles, but not of the nerves, is 
greatly increased, so that percussion of a nerve may have no effect, but 
percussion of a muscle will produce a prolonged contraction. The elec- 
trical excitability of the nerves is altered. According to the researches 
of Erb and Huet, the faradic reaction of the muscles may be normal, or 
there may simply be a tendency for the muscles to be thrown by very 
slowly interrupted currents into myotonic spasm lasting from ten to 
twenty seconds ; but even a weak faradic current applied to the nerve 
will produce tonic contractions, lasting for a long time after the with- 
drawal of the current. On the other hand, the galvanic excitability of 

4 



50 



GENERAL DISEASES. 



the nerve is somewhat lessened, whilst the galvanic muscular excitability- 
is increased. There is often also a qualitative change in the muscle, the 
closure and opening contractions becoming equal or even inverted. 
When a strong galvanic current is passed uninterruptedly along the 
muscles, rhythmic undulations occur, which commence near the cathode 
and pass forward towards the anode. For the development of this a 
strong current must be used, one electrode being placed upon the back 
of the neck, the other upon the arm or the hand. Epilepsy, chorea, 
and various nervous symptoms have been present in cases of Thomsen's 
disease, but they are only accidental complications. 

Diagnosis. — The symptoms of Thomsen's disease may be so latent as 
to appear only after exposure to cold, but are always characteristic when 
they occur. Eulenberg has described under the name of paramyotonia 
congenita a case in which, after exposure to cold, there was a tonic con- 
traction lasting from a quarter of an hour to several hours and followed 
by paralytic weakness. Mechanical excitability of the muscles was not 
increased, and the eye-muscles were affected. 

Prognosis and Treatment. — Complete recovery probably never 
occurs. Sometimes there are remissions, and there seems to be no ten- 
dency to a fatal ending. ~No known treatment is of avail. 

RICKETS. RACHITIS. 

Definition. — A disease of early childhood, characterized by abnor- 
malities in the growth of the bones. 

Etiology. — A distinction is to be drawn between true rickets and 
disturbances in the growth of bone which have been regarded as varieties 
of rickets.* 

The designation late or tardy rickets is applied to the occurrence of 
changes resembling those in rickets in childhood or in adult life. Eickets 
is found with equal frequency in males and in females, the manifestations 
beginning during the first two years of life, although usually not earlier 
than the fourth month. It is doubtful whether rickets is inherited, 
although the disease may exist in successive generations and in children 
of the same family. It is possible that a congenital predisposition may 
exist based upon debility of the parents, whether from disease, as tuber- 

* Most important of the latter is congenital or foetal rickets. In this affection, ac- 
cording to Kaufmann, there is an arrest of the growth of the epiphyseal cartilage and 
a degeneration of the cells. Thus the longitudinal growth of the bone is checked, 
while the periosteal growth continues. In consequence of the shortening of the base 
of the skull the root of the nose is depressed and the vault of the cranium height- 
ened. The extremities are short and thick. The deformity thus resulting resem- 
bles that occurring in sporadic cretinism or congenital myxcedema. Foetal rickets, 
however, is not common where cretinism prevails, and does not especially occur in 
goitrous families. There is no enlargement of the thyroid as in cretins, or atrophy 
as in congenital myxcedema. Furthermore, there may be no mental disturbance in 
foetal rickets. 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



51 



culosis or syphilis, or from faulty hygienic surroundings. The view ad- 
vanced by Parrot, that rickets is a manifestation of congenital syphilis, 
is not generally accepted, since this disease occurs without other mani- 
festations of syphilis, and the changes in the epiphyseal cartilage differ 
from those of syphilis. The disease prevails in the larger cities of Middle 
Europe. According to Cohn, upwards of sixty-five per cent, of the cases 
appearing at the Berlin Polyclinic show manifestations of rickets. It is 
rarely found strongly pronounced in the native white American, but is 
frequent among negroes living in cities. Local causes are of the utmost 
importance in the production of rickets. They are to be found in faulty 
food, especially in artificial feeding, particularly when the food is of 
excessive quantity or unduly farinaceous. The effects of improper feed- 
ing are exaggerated by poor hygienic surroundings, as cold, dampness, 
and absence of sunlight and fresh air. It has been suggested that malaria 
may be of importance in the etiology of rickets. 

Morbid Anatomy. — The changes in the growth of bone character- 
istic of rickets proceed from the epiphyseal cartilage and the periosteum, 
and are regarded by Kassowitz as inflammatory. They consist in a luxu- 
riant growth of the epiphyseal cartilage and an excessive elongation in it 
of the osteoid trabecular, with the formation of marrow-spaces in the car- 
tilage unusually remote from the diaphysis. The ends of the bone become 
thickened, and long after calcification has taken place islets of cartilage 
may remain in the ends of the long bones. The periosteum becomes 
thickened. New-formed blood-vessels arise in its deeper layers, and the 
osteoid trabecular are thin and elongated. An absorption of bone also 
takes place from the marrow-spaces. In consequence of this excessive 
growth of osteoid tissue without simultaneous calcification, the bones 
become thick and soft, are easily bent and broken, the fractures being 
of the green-stick character, and thus various deformities arise. When 
recovery takes place the bones are unusually strong, since the lime 
salts are deposited in those which are abnormally thickened, and the 
pre- existence of rickets may thus be apparent even in old age. In the 
cranium the alterations may take place in the occipital and parietal 
bones, and are manifested by delayed ossification as well as by irregu- 
larities in growth into the sutures, and in the closure of the fonta- 
nelles. Deformities of the spine, of the thorax and pelvis, and of the 
bones of the extremities, especially of the lower, take place. Enlarge- 
ment of the liver and spleen is frequent. 

The fontanelles are large, and the anterior fontanelle may remain 
open until the third year instead of being practically closed early in the 
second year. Various degrees of hydrocephalus may arise, and the head 
may become squared in consequence of thickening of the frontal and 
parietal bones. As a result of the alterations of the intervertebral carti- 
lages, curvatures of the spine occur. The sternum protrudes from weak- 
ening of the costal cartilages, and the child becomes pigeon-breasted. 



52 



GENERAL DISEASES. 



If the sacro-iliac synchondroses are especially diseased, the sacrum and 
symphysis are approximated and the lateral diameter of the pelvis is 
widened. If the pubic cartilages are especially diseased, the anteropos- 
terior diameter may he elongated. The thickening of the epiphyseal ends 
of the bones gives rise to the term double-joint, while the yielding of the 
weakened bones to the weight of the body is manifested by the deformi- 
ties known as bow-legs and knock-knee. The enlargements of the epi- 
physeal ends of the bones of the arm are more frequent at the lower 
end of the radius and ulna, and are attributable to the use of the hands 
and arms in crawling. Such deformities may prevail in the cranium, 
thorax, and spine, or in the extremities, or all these regions of the body 
may become affected. 

Symptoms. — The symptoms of rickets are usually of gradual develop- 
ment as the period of dentition approaches, and are often attributable to 
teething. They are more likely to begin in the winter months. The in- 
fant becomes fretful and restless, and perspires readily, especially from the 
head and neck. The stools become frequent, green, and slimy, although 
the appetite remains good. The infant awakes suddenly from a sound 
sleep with loud cries as if terrified, and convulsions and tetany and 
various nervous disturbances may occur. (See page 441. ) Spasm of the 
glottis, bronchitis, and broncho-pneumonia are frequent, and irregular 
elevations of temperature take place. The abdomen becomes distended, 
although emaciation is usual, and the patient is weak and pale. The 
significance of these general symptoms is apparent when physical exam- 
ination discloses the soft spots in the occiput (craniotabes) or parietal 
bones, or the beaded condition of the costal cartilages, the last form- 
ing the rosary of rickets, which is due to the thickening of the carti- 
laginous ends of the ribs. With the advance of the disease the child 
objects to being handled, through fear of pain, and refuses to sit up or 
walk. Dentition is delayed, and the fontanelles remain open. The head 
becomes large, and deformities of the spine and extremities arise. Such 
deformities may be greater in the head, thorax, and spine or extremities, 
or all these regions of the body may be affected. The child remains 
pale, the tissues flabby, and the intelligence dull. Intercurrent inflam- 
matory affections, especially bronchitis, broncho-pneumonia, and atelec- 
tasis, are frequent, particularly when the thorax is affected. The course 
of rickets is usually slow, but rapid cases with pronounced fever occur. 

The duration of the disease varies, and in accordance with the age at 
which it begins and the time it continues do the localization and extent 
of the deformities vary. Eickets beginning in the early months of life 
and continuing for months or years results in deformities of the head, 
trunk, and extremities. Eickets beginning at the same time and lasting 
but a few weeks may produce little alteration of the skeleton, or may 
cause changes localized in the skull, spine, and thorax while the extremi- 
ties are but slightly affected. On the contrary, rickets coming on after 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



53 



the first year of life produces deformities of the extremities, thorax, and 
spine, while the cranium shows but little change. 

Diagnosis. — It is a matter of the gravest practical importance to 
recognize the first beginnings of rickets. "When, during the second half- 
year of life, there are obstinately recurring digestive disturbances, soft, 
white, tender flesh, and delayed, irregular dentition, the nature of the 
case should be recognized before local sweating of the head, the pecu- 
liarities of the fontanelles, and bony deformities give precision to the 
diagnosis. 

The only disease which can produce changes in the bones similar to 
those of rickets is hereditary syphilis. This disease is to be differen- 
tiated by the presence of other syphilitic changes. Although craniotabes 
is one of the early manifestations of rickets, it may occur independently 
of this affection. More characteristic is the presence of the rosary, which 
usually appears before conspicuous alterations in the cartilaginous ends 
of the long bones. It is to be remembered that one or several of the 
costal cartilages may be affected. The bruit which can often be heard 
on auscultation over the anterior fontanelle is not diagnostic, as it is 
liable to occur in chronic hydrocephalus or whenever from any cause 
closure of the fontanelles is delayed ; indeed, it is sometimes audible in 
perfectly healthy children. 

Prognosis.— Rickets is a disease which may be arrested at any 
stage by appropriate treatment. The prognosis thus is favorable as to 
an arrest of the process, although the existing deformities may persist. 
During the progress of rickets death is frequent from the complications 
in which the respiratory apparatus is involved : hence the frequency 
of death in rachitic children from measles, whooping-cough, and bron- 
chitis. The permanent alterations occurring in protracted rickets are 
frequent sources of the permanent stunting of the growth of the indi- 
vidual, shown by some of the dwarfs to be found in most large com- 
munities. In the female the rickety deformity of the pelvis proves 
a source of serious, if not of fatal, interference with labor, Cesarean 
section often being necessary in the effort to save the life of mother and 
child. 

Treatment. — In rickets it is essential that the child be put under the 
most favorable hygienic surroundings possible. The question of feeding 
is one of the greatest importance. Good healthy breast-milk is the proper 
food for an infant under one year of age ; but, in our experience among 
the well-to-do, bad milk upon the part of the mother or of the wet-nurse 
is not a rare cause of a rachitic condition. It is essential that nurses be 
healthy, be sufficiently but not over-fed, have abundant exercise, and 
furnish a plentiful supply of milk with the proper physical characteristics. 
In any case of rickets occurring in a wet-nursed child the question of 
the milk used should be most carefully investigated, even by chemical 
examination. Moreover, the amount of milk should be sufficient. Ac- 



54 



GENERAL DISEASES. 



cording to the researches of Lewis Smith, the child should have in the 
first year of infancy, — 



At each Feeding. 



Number of 
Daily Feedings. 



Total 
Daily Amount. 







10 


10 ounces. 


Third week 


. . 1J ounces. 


10 


15 " 


Sixth week 


. . 2 " 


8 


16 " 


Third month 


. . 3 " 


8 


24 " 




. . 4 " 


7 


28 " 




. . 6 " 


6 


36 " 


Tenth to twelfth month . . 


. . 8 " 


5 


40 " 



Under no circumstances should a pregnant woman he allowed to suckle 
a child, as either the offspring or the mother must be starved. When 
breast-milk cannot be procured, the best results are probably obtained by 
a very careful admixture of cow's milk and Mellin's, Nestle' s, or other 
artificial infants' foods. 

In older children the diet should consist of an abundance of milk, 
easily digested farinaceous food (not oatmeal, unless the child's diges- 
tion is extremely good), and meat once or twice a day. Disturbances 
of the digestive organs should be carefully treated by the use of pepsin, 
sodium phosphate, bismuth, or other remedies, pro re nata. 

The rachitic child should always be warmly clad ; should be kept in 
the sunshine in the open air as much as possible, even on cold days, 
proper protection being afforded by wraps ; should be bathed daily, and 
after the bath should be freely anointed with cotton-seed, olive, or other 
bland vegetable oil, or preferably with cod-liver oil, which should be 
well rubbed in. Great care should be taken to prevent deformities by 
keeping the child off its feet, or in extreme cases even from sitting up, 
and by the use of splints or other mechanical contrivances. In older 
children massage may be useful to replace natural exercise. 

When it can be digested, cod-liver oil is a most important remedy ; 
it is usually best given in the form of the emulsion with lactophosphate 
of lime. Iron seems to be demanded by the existing ansemia, and, unless 
it disturbs the digestion, is generally serviceable. It should, however, 
be given in small doses, and its effect upon the alimentary canal most 
carefully watched. Phosphorus is a very valuable remedy in rickets ; 
one two-hundredth of a grain may be given three times a day after food, 
in the form of the official elixir, of which one teaspoonful contains one- 
sixty-fifth of a grain of phosphorus, or dissolved in oil. Owing to the 
avidity with which phosphorus takes oxygen, such minute quantities of 
it frequently suffer destruction : hence the practitioner should always see 
that the preparation has been freshly made and has a distinct odor and 
taste of the drug. The dose should also be increased as borne. 

The numerous nervous, pulmonic, and digestive complications of the 
rachitic state should be carefully treated by remedies which would be 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



55 



suitable for the same conditions not arising in the general rachitic dis- 
turbance of nutrition, but it should always be remembered that the pul- 
monic, nervous, or other accident of the disease is best cured by curing 
the basal disorder. 

HEMORRHAGIC RICKETS. INFANTILE SCURVY. BARLOW'S 

DISEASE. 

This affection, although classified by some authorities as a variety of 
rickets, and by others as a variety of scurvy, is perhaps rather a disease 
sui generis, both resembling and differing from scurvy and rickets. The 
occurrence of its symptoms and lesions without any manifestations of 
rickets demands its consideration independently of that disease. Its fre- 
quent association with rickets, and its occurrence at the same period of 
life and in connection with a similar diet, suggest an intimacy of relation 
to rickets. It resembles scurvy in its origin from too exclusive a diet 
and from the conspicuous hemorrhagic lesions. It differs from scurvy 
in being found in regions where the latter disease is rare, in its absence 
from countries, as Russia, where scurvy prevails, and in being a disease 
limited to infantile life, occurring in solitary cases and not as an epi- 
demic. In scurvy hemorrhages in the skin, gums, and joints are the 
rule, while in hemorrhagic rickets the bleeding is largely periosteal. It 
is generally admitted that the first case of the kind was published by 
Moller in 1857, who regarded it as an instance of acute rickets. Cheadle 
in 1878 considered the affection as rickets complicated with scurvy. 
Barlow in 1883 published his important paper on the subject which has 
led to the general association of his name with this affection. 

Etiology. — Hemorrhagic rickets, like rickets, is a disease of infantile 
life, and is due to improper food. Particularly injurious has proved the 
exclusive use of condensed milk, or of various prepared infants' foods, 
although freshly prepared cow's milk and even breast-milk have given 
rise to the disease. Unlike rickets, it prevails among children of the 
well-to-do or of those in moderate circumstances with good hygienic sur- 
roundings, and is frequently seen in the country. Its occurrence in con- 
genital syphilis has also been observed. Furst suggests that the faulty 
diet produces a cachexia, either rachitic or hemorrhagic or a combination 
of both, according as there is a lack of calcium phosphate or of potassium 
phosphate or of both salts. 

Morbid Anatomy. — The characteristic changes are found in connec- 
tion with the bones, especially of the extremities, the femur being oftenest 
affected. The cranium and jaw are rarely attacked. The periosteum is 
thickened, injected, and is separated from the shaft of the bone by more 
or less extensive hemorrhage. When rickets is associated the epiphyses 
are swollen and may be separated. Hemorrhages and oedema may occur 
in the intermuscular tissue. In fatal cases cutaneous hemorrhages may 
be found. 



56 



GENERAL DISEASES. 



Symptoms. — The symptoms of this disease are of most frequent occur- 
rence towards the end of the first year of life, although they have been 
observed in infants of six months. They may develop suddenly or gradu- 
ally, the child appearing well nourished and even plump, although some- 
what pale. The patient is fretful, cries when touched, dreads to be 
moved, and becomes extremely weak and unable to sit upright. The ex- 
tremities are semiflexed, and fusiform swelling, especially of the thighs, 
appears. Similar thickenings, though less extreme, may occur in the 
upper extremities and upon the scapula. The enlargement is resistant, 
the skin tense. Eventually the swelling becomes elastic, perhaps flattened. 
In the further progress of the disease the pale skin may present a faint 
yellow tint. If rachitic changes are associated, the epiphyses, especially 
of the femur and tibia, when separated yield to the touch. Hemorrhages 
from the mouth often occur at dentition, and more rarely cutaneous hemor- 
rhages are observed. The temperature is usually slightly elevated while 
the hemorrhage is taking place, and there is then considerable perspiration. 

Diagnosis. — The rapid occurrence of pain on motion of the lower 
extremities, followed by swelling in the vicinity of the joints, which are 
themselves not affected, in infants artificially fed, should suggest hemor- 
rhagic rickets. The local symptoms may be confounded with those of 
articular rheumatism, but the temperature is less elevated, sweating is less 
considerable, and the appetite of the child is but little affected. The 
rarity of acute rheumatism in infancy is also opposed to this diagnosis. 

Prognosis. — The prognosis is favorable, although fatal cases have 
occurred. Of one hundred and sixty-six cases referred to by Fiirst, 
sixty-seven per cent, recovered, eighteen per cent, died, and in fifteen 
per cent, the result was unknown. Eecovery is usually rapid with the 
early recognition of the disease and the use of appropriate diet. 

Treatment. — Antiscorbutic treatment, with careful regulation of the 
diet and hygienic management of the child, should first be tried : if this 
fail the treatment should be that of rickets. Barlow recommends locally 
the use of wet compresses and avoidance of movement during the acute 
stage, followed after a time by careful shampooing. 

OSTEOMALACIA. 

Definition. — A chronic disease of the bones of the adult, resulting 
in their softening and characterized by a transformation of bone-tissue 
into marrow. 

Etiology. — Osteomalacia is a rare disease, especially prevalent in 
certain countries, particularly in Germany, Switzerland, and Italy, and 
especially in certain localities such as the borders of the Ehine and 
mountain valleys ; hence it has been regarded as endemic. It is found 
nearly ten times as often in women as in men, and usually in those 
from twenty to thirty years of age. Faulty hygienic surroundings are 
regarded as predisposing causes, but pregnancy is generally agreed to be 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



57 



of especial importance. The disease is more likely to occur in those in 
whom pregnancies take place at short intervals, and twin pregnancies 
often occur in women with osteomalacia. Fehling maintains that ovarian 
disease is a cause of osteomalacia, and that the favorable results of cas- 
tration demonstrate the truth of the theory. A distinction is drawn 
between puerperal osteomalacia and senile osteomalacia. The former 
variety includes nearly three-fourths of the cases. Senile osteomalacia 
affects rather the bones of the thorax and pelvis, while in puerperal 
osteomalacia the entire skeleton may be attacked. The term infantile 
osteomalacia has been applied to certain cases of rickets. 

Morbid Anatomy. — The changes resemble those found in rickets, 
but are not present in the vicinity of the epiphyseal cartilage. The 
trabecule of the bones are largely composed of osteoid tissue, owing per- 
haps to decalcification, perhaps to new formation of osteoid tissue. The 
marrow is hyperplastic and excessively vascular. With the advance of 
the process the affected bone becomes so softened that it may be cut, and 
cavities of considerable size arise within the shaft by a cystoid metamor- 
phosis, — their walls being composed of a thin layer of osteoid tissue and 
periosteum, while the contents are a gelatinous, transformed marrow. 
The weakened bones get bent and broken, and Orth pictures the healing 
of such fractures with osteoid tissue in which are no lime salts. The 
spine becomes curved, the ribs flattened and depressed, the antero -poste- 
rior diameter of the pelvis elongated, the transverse diameter shortened, 
while the bones of the extremities, especially the lower, are shortened, 
distorted, and brittle. The bones of the cranium and face are usually 
unaffected. Atrophy and cystic degeneration of the ovaries have fre- 
quently been observed. 

Symptoms. — Pain is the first symptom complained of, and in the 
osteomalacia of pregnancy usually makes its appearance during the later 
months of gestation. It is then dull, persistent, increased by prolonged 
muscular action, and is referred to the pelvis and sacrum. In the non- 
puerperal cases the pain is referred to the spine, chest, or legs. The pain 
may be localized in certain bones, and is perhaps aggravated on pressure. 
In puerperal osteomalacia relief to the pain usually takes place between 
successive childbirths, and aggravation occurs during pregnancy, some- 
times at menstruation. With the persistence of the disease the pain 
eventually disappears, but the walk of the patient is affected. The 
gait is stiff, somewhat spastic, and the patient easily gets tired. The 
stature of the patient becomes lowered from curvature and shortening 
of the spine. The functions of the body other than those of respiration 
and parturition are but little affected. Deformity of the thorax may 
cause dyspnoea and palpitation, while deformity of the pelvis prevents 
the passage of the foetus. Fibrillary muscular twitchings occur. The 
patients lose flesh. The skin is pale and the haemoglobin is diminished. 
Various examinations of the blood have been made, but no characteristic 



5S 



GENERAL DISEASES. 



appearances have been found. Albnmose has frequently been detected 
in the urine. The disease is ordinarily of long duration, exacerbations 
and remissions occurring, and puerperal osteomalacia often ceases at 
the climacteric. 

Diagnosis. — In the early stages the diagnosis may be difficult, since 
the pain in the back or pelvis may be regarded as lumbago or neuralgia. 
The suggestion of osteomalacia as a cause is based upon the association 
of the pain with pregnancy and upon the nationality and previous sur- 
roundings of the patient. In the later stages the deformity of the bones 
is sufficiently characteristic. 

Prognosis. — Until recently this disease was regarded as almost in- 
evitably fatal, although periods of temporary improvement might occur 
and the patient might live for years. It is now recognized that under 
appropriate treatment a cure may take place, provided the disease is 
early recognized. In cases of recovery the bones may become abnormally 
dense from an excessive deposition of lime salts. 

Treatment. — The treatment of osteomalacia consists in putting the 
patient under the best possible hygienic surroundings ; in the especial 
giving of foods, such as whole wheat flour, which contain the natural 
phosphates ; and in the administration of tonics, of iron or cod-liver oil, 
of the calcium phosphates, and of phosphorus itself. Warm baths some- 
times afford much relief. Numerous cases of arrest and cure of the dis- 
ease have followed ovariotomy and Porro's operation. Married women 
suffering from the disease should always be warned against the danger of 
pregnancy. 

OBESITY. 

A tendency to excessive corpulence occurs in certain races of men, as 
the Jews, and is also a characteristic of certain families. Probably in 
the majority of cases, however, it is due to one or more of three causes : 
first, over-eating ; second, under-exercising j third, the excessive use of 
alcohol. In judging of the individual case it should always be remem- 
bered not only that corpulence may exist without being excessive and 
without requiring rigid treatment, but that what is excessive in one indi- 
vidual may not be so in another ; and even in the same individual the 
amount of allowable corpulence varies at different ages. In the young 
any superfluity of fat, unless in a person of pronouncedly corpulent in- 
heritance, is usually the result of over- eating and physical indolence and 
must be looked upon as pathological. In the middle-aged a moderate 
amount of fat is physiological, and to be rather encouraged than dis- 
couraged. Again, women normally carry more adipose tissue than do 
men. Whenever the weight becomes so burdensome as to interfere with 
walking, or to cause puffiness or shortness of breath in going up-stairs 
or ascending heights, treatment should be instituted. The symptoms of 
cardiac disturbance and shortness of breath due simply to excessive fat 
in the system and about the heart may be so severe as to simulate organic 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



59 



disease ; and there can be little doubt that in many of these cases there 
is an actual deposit of fat between the muscular fibres in the heart- wall 
which interferes with the action of the viscus. 

Excessive corpulence is to be combated by exercise and regulation 
of the diet, and sometimes by medication. In the use of exercise it is es- 
sential to remember that the corpulent person is usually feeble and often 
has a softened heart and arteries. The amount of exercise, therefore, must 
be graded to the individual, whilst the form of it is almost always domi- 
nated by surrounding circumstances. The essentials are, first, that the 
exercise should involve most or all of the muscular system ; second, that 
it should be sufficiently severe, if not at first, as soon as possible, to pro- 
duce free perspiration ; third, that it should never be enough to produce 
an exhaustion which will show itself in sleeplessness or in markedly in- 
creased debility the day following ; fourth, that it should be steadily per- 
sisted in day after day, and gradually increased as fast as the patient's 
strength will allow. In all severe cases, when practicable, the exercise 
should be followed by a bath, a thorough rubbing down, and rest in bed. 
Outdoor exercise is preferable to in-door ; exercise that gives variety and 
pleasure to the patient is much superior to exercise which is irksome. 
A careful, cautious trainer, if prevented from overdoing by rigid medical 
supervision, will often aid greatly. 

In regulating the diet in a case of obesity it should be remembered 
that the fat contained in the food may be directly deposited in the body, 
but that albuminoid foods in their decomposition and destruction in the 
body certainly yield fat, although it is practically demonstrated that 
they do not increase corpulence as much as do the carbo-hydrates. It is 
evident, therefore, that those systems of dieting which consist simply in 
the withdrawal of fats and carbo-hydrates and their substitution by 
albuminous nitrogenous foods are not completely satisfactory, and that 
usually it is essential for the physician to regulate the quantity as well 
as the quality of the food. 

The severity of the diet should depend upon the severity of the 
condition to be combated. In mild corpulence withdrawal of all alcohol 
and avoidance of excess of eating, with increased exercise, may suffice. 

Bantingism, or the method of treatment of corpulence which consists 
especially in putting the patient upon an almost entirely meat diet, as 
advocated by Harvey, encounters in practice several difficulties. There 
is always the danger of an excessive strain upon the kidneys in the elim- 
ination of nitrogenous educts through an over- abundant supply of meat. 
This, however, is usually to be averted by rather decreasing the hydro- 
carbons in the food than increasing the nitrogenous elements. The physi- 
cian should examine the urine of the patient once every ten days, so that 
the diet may be altered if albumin be found. In order not to be mis- 
led, the practitioner should bear in mind the fact that violent exercise 
may of itself produce albuminuria. 



60 



GENERAL DISEASES. 



More valid objections to Bantingism are found in the chilliness, the 
weakness, and the ever-increasing repugnance to meats produced by a 
too rigid restriction to albuminous foods. Moreover, in some cases severe 
dyspeptic and especially gouty arthritic symptoms are produced by a 
rigid flesh diet. To meet these objections Professor Ebstein modified 
the plan of Dr. Harvey by adding fatty food, and allowed the following 
dietary : 

Breakfast. — Tea without sugar or milk ; one and a half ounces of 
white bread, with plenty of butter. 

Lunch. — Fatty soup made from a marrow -bone ; four to seven ounces 
of flesh containing much fat ; some vegetables ; stewed fruit without 
sugar ; two or three glasses of wine. Later in the afternoon, one cup 
of tea without milk or sugar. 

Evening. — One cup of tea without milk or sugar ; one ounce each 
of bread and butter ; one egg, or a piece of fat ham, or fat roast meat, 
or cheese 5 fresh fruit. No alcohol. 

The following dietary is a modification of that of Harvey which we 
think may ordinarily be followed : 

Breakfast. — Grape-fruit or orange ; four ounces of lean meat or five 
ounces of fish ; four ounces of bread j tea or coffee. 

Lunch. — Two ounces of lean meat, oysters, or fish ; three ounces of 
brown bread ; raw fruit pro re nata, except grapes and bananas. 

Dinner. — Half a pint of soup ; two ounces of fish ; three ounces of 
lean meat 5 two ounces of gluten bread ; six ounces of green vegetables. 

In some cases of corpulence it is not necessary to enforce the diet as 
strictly as that given, only to cut off potatoes and sugar and reduce the 
amount of white bread. In all cases the weight should be taken from 
week to week, and care be exercised that the loss is not too rapid. 
When the repugnance for meat becomes pronounced it is very often well 
to intermit the rigidity of the diet. The question of the amount of water 
to be used is a very difficult one to answer. So far as our present physi- 
ological knowledge reaches, there appears to be no scientific reason for 
reducing the ingestion of liquid, but from time immemorial trainers 
have insisted upon abstinence from drinking. There is no reason why 
alcohol should be allowed ; but, if the patient insist on it in some form, 
thin sour wines are the best. 

A mistake which we have very frequently seen made is the over- 
doing of the thinning process : there are many persons who are not in 
good health unless they carry with them more fat than is needed for 
aesthetic purposes or than would seem to be useful for comfortable living. 

In making a modified diet list for a case of obesity, lean meat, in- 
cluding game, chicken, fish, lobsters, and oysters, young green vege- 
tables, such as peas, beans, spinach, cabbage, cauliflower, asparagus, 
salads, celery, and tomatoes, gluten bread, and almonds, may be freely 
allowed. Articles which should be used in very small quantities or alto- 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



61 



gether forbidden are butter, cream, fats, sauces, tame geese and ducks, 
eels, salmon, pastries and all kinds of confectionery, and potatoes. The 
foods to be taken in small quantities are bread, buckwheat cakes, milk, 
and eggs. 

It is doubtful whether any known drugs have the power of reducing 
the amount of fat in the body, except by purging, interfering with di- 
gestion, or producing in some way a diseased condition. There are, 
however, many corpulent persons who are habitually anaemic. Under 
such circumstances the use of iron in moderate quantities may be of ser- 
vice. As a restricted diet has a great tendency to produce constipation, 
it is essential that laxatives be employed when needed. In Germany cer- 
tain springs, especially Marienbad and Carlsbad, have a great reputation 
in the treatment of obesity. We believe that the results obtained are 
largely due to the diet and exercise enforced, but it is probable that the 
free purging which these waters produce brings about a normal condition 
of the digestive apparatus, prevents the absorption of food by hurrying 
it out of the intestines, and probably aids in the reduction of corpulence. 
It is also possible that the excess of alkali may aid in removing the fat. 
The spring treatment may be imitated with success by giving a mixture 
of salines and alkalies, or of salines with iron in ana3mic subjects. (See 
formulae 2 and 3.) 

Thyroid extract is stated to have done good in certain cases of ex- 
cessive obesity ; and when the fat-making tendency of the body amounts 
to a disease, so that the condition cannot be overcome by the use of the 
normal methods of restricting fat-production in the body, the extract 
should be tried as in myxoedema. (See Myxoedema. ) 

ACUTE ARTICULAR RHEUMATISM. RHEUMATIC POLYARTHRITIS. 

RHEUMATIC FEVER. 

Definition. —An acute febrile disease, believed by many authorities 
to be of infectious origin, characterized by inflammation of various joints 
in succession, profuse sweating, and a tendency to endocardial inflam- 
mation. 

Etiology. — Acute articular rheumatism is a disease widely distributed 
throughout the world, especially in regions where there is considerable 
moisture. It occurs most frequently in the colder months, least often 
during midsummer. Both sexes are alike affected, especially during 
early adult life, and it is rare in infancy and old age. It prevails in cer- 
tain families, and some authorities are of the opinion that a gouty inheri- 
tance strongly predisposes the young to attacks of acute rheumatism, 
while later in life muscular rheumatism, and still later unmistakable 
gout, become manifest. According to others, gout and acute rheuma- 
tism rarely occur in the same person, and members of gouty families are 
not especially prone to acute rheumatism, nor are families showing a 
strong hereditary predisposition to rheumatism particularly liable to the 



62 



GENERAL DISEASES. 



manifestations of gout. The endocarditis of rheumatic fever is acute and 
usually associated with the presence of bacteria, while that of gout is 
chronic, without bacteria and with degenerative aortic changes. Eheu- 
matic fever is especially found among persons whose occupation exposes 
them to sudden and extreme changes of temperature, when profuse per- 
spiration is quickly checked by cold draughts of air. Local conditions 
are important, since numerous cases occur in limited localities, and Dal- 
ton has observed an apparent etiological importance in leaky drains. A 
certain resemblance of the symptoms and lesions to those found in gout 
has suggested that obscure modifications in the metamorphosis of tissue 
may result in a toxaemia, oftenest attributed to an excess of uric or of 
lactic acid in the fluids of the body, but thus far no such excess has been 
found. Eichardson affirms that he has produced rheumatism by the 
administration of lactic acid. This theory and his observations lack 
efficient confirmation. 

The theory of the infectious origin of rheumatism is the most popular 
at the present time. It is based upon the resemblance and similarity of 
distribution of many of the lesions to those found in septicaemia and 
pyaemia, the frequency of relapses, and the occasional occurrence of 
arthritis in such infectious diseases as scarlet fever and dysentery ; ad- 
ditional support is derived from the occurrence of apparent epidemics at 
certain seasons in limited localities, especially in households, and the 
discovery of bacteria in the fluids from the joints and from the inflamed 
endocardium and pericardium. Sahli has recently found throughout the 
body a coccus morphologically identical with the staphylococcus citreus, 
and Singer finds a variety of bacteria in the urine from cases of acute 
rheumatism. 

According to this view, the joints, like the spleen, lymph-glands, and 
bone- marrow, represent a structure especially susceptible to the action 
of bacteria or their toxins. A suppurative inflammation of the joints 
readily occurs in pyaemia and puerperal fever, and the introduction of 
pyogenic cocci into an injured joint is followed by suppuration, and 
in the inflamed joints in gonorrhoea pure cultures of the gonococcus 
have been found. It is thus plausible that a rheumatic arthritis may 
represent a mild variety of pyaemia or septicaemia, the milder character 
of the lesions perhaps resulting from the action of an enfeebled bacterium 
or attenuated toxins. The observation made by Sahli suggests that the 
various local lesions of acute rheumatism may result from a multiple 
localization of bacteria. No specific bacterium has been found, but it is 
possible that various bacteria may be concerned, and that other factors 
may be necessary. 

Morbid Anatomy. — The anatomical changes consist essentially in a 
sero-fibrinous inflammation of the joint and the neighboring tissues. 
The synovial membrane is swollen, injected, hemorrhagic, and the syno- 
vial fluid is increased in quantity, opaque yellow, flocculent, and contains 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 63 

red and white blood- corpuscles. The exudation is sometimes sufficiently 
opaque from the presence of leukocytes to be regarded as purulent, 
although true pus rarely exists. An opaque-yellow infiltration of the 
tissues near the joint, including the bursse, tendon-sheaths, and connec- 
tive tissue, is frequent, and hemorrhage may occur. Abscesses in these 
tissues are rare, and disease of the bone and cartilage is infrequent, if 
the occasional termination in chronic articular rheumatism is excluded. 

Symptoms. — According to the nature and severity of the symptoms 
a distinction is made between acute, subacute, and chronic articular 
rheumatism, although the last, in most cases at least, is probably a dif- 
ferent disease in etiology, symptoms, and results, and will therefore 
receive independent consideration. Acute articular rheumatism is of 
rapid onset, sometimes appearing within a day or two after the sudden 
exposure of a heated person to cold. The patient complains of chilly 
sensations, which are soon followed by a fever with morning remissions 
and evening exacerbations, the extreme elevation rarely being above 
104° F. Tonsillitis is at times present, and may precede or accompany 
the arthritis. The joints now become red, swollen, and painful. Sym- 
metrical joints are usually affected, and recurrences are frequent. At 
first the articulations of the lower extremities are usually inflamed, then 
those of the upper, more rarely the hip, jaw, vertebrae, and pelvic sym- 
physes. The swelling of the joint is largely due to the exudation into 
the synovial cavity, which may be sufficient to cause fluctuation, but it is 
partly dependent upon oedema of the surrounding tissues. The pain is 
often severe, and may become intense on motion of the joint ; it is usually 
worse at the outset of the inflammation and diminishes as the exudation 
increases. It may be limited to the joint or may extend along the course 
of the neighboring tendons or nerves. One or many joints may be in- 
flamed, the inflammatory process tending to move from joint to joint 
without following any definite order, diminishing in the one as it in- 
creases in the other. In the milder cases the affected joint is freed from 
the inflammatory disturbances in the course of a few days. In the severer 
cases the arthritis may persist for several days. Profuse sweating accom- 
panies the inflammation of the joints, increasing as new joints are at- 
tacked, and the perspiration has a sour odor and an acid reaction, but 
does not contain lactic acid. Headache, loss of appetite, and nausea 
accompany the fever. The pulse is quickened, its tension diminished. 
The respiration is somewhat accelerated. The range of temperature at 
first shows but little daily variation, but exacerbations take place as new 
joints are attacked, and remissions of temperature occur as the inflam- 
mation subsides. A continued high elevation of temperature remains for 
some time after the swelling of the joints subsides. The urine is scanty, 
high-colored, its specific gravity 1025 to 1030, and there are abundant uric 
acid and urates. Uric acid may be absolutely increased or diminished ; 
urea is often diminished. A trace of albumin may be present. As the 



64 



GENERAL DISEASES. 



fever subsides, the urine becomes abundant and pale, and peptone is said 
to be present as the inflammation of the joints lessens. 

Austin Flint has shown that the duration of acute articular rheuma- 
tism may be but little affected by treatment. In uncomplicated cases the 
disease lasts from one to six weeks, and in cases of moderate severity at 
least four weeks of illness may be expected. In severe cases, especially 
those in which complications exist, despite all treatment a period of 
several months may elapse before the patient is convalescent. The term 
subacute rheumatism is applied to cases of rheumatic fever of a mild type. 
Fewer joints are affected, pain, redness, and swelling are less extreme, 
the temperature is lower, and the sweating less, but the course is often 
protracted. Complications may occur, and it is to be remembered, espe- 
cially in the febrile rheumatism of children, that the complications may 
be more serious than the arthritis, although the range of temperature may 
follow a subacute course. 

Among the most frequent and important of the complications of rheu- 
matic fever is endocarditis, which takes place in nearly one-fourth of 
the cases, whether mild or severe, especially in the young. In a certain 
number of cases pericarditis is present, with or without endocarditis, and 
inflammation of the myocardium may also occur. These cardiac compli- 
cations may intervene at any time during the course of the disease, but 
are more likely to be made manifest during the second week. Localization 
of the rheumatic inflammation in the heart may be indicated by pain, 
palpitation, an irregular pulse, rapid breathing, a sense of oppression 
referred to the heart, and a rise of the temperature, although these symp- 
toms are no necessary evidence of affection of the heart. The presence 
of a pericardial rub or an endocardial murmur may be the only symptom, 
and time is often necessary to determine the nature of the murmur in 
virtue of the relative frequency of hseniic murmurs in acute rheumatism. 
The mitral valve is oftenest diseased, either alone or with simultaneous 
affection of the aortic valve. Eheumatic inflammation limited to the 
latter is rare. The pericardial exudation is both serous and fibrinous, 
and its extent is to be determined by the physical examination of the 
heart. (See Pericarditis, Section III.) The exudation may be rapidly 
absorbed or may be so excessive as to be the immediate cause of death. 
Delayed absorption of the exudation is likely to result in permanent 
adhesions. 

Pleurisy, more rarely pneumonia, may occur during the progress of 
acute rheumatism. The former prevails on the left side, and is frequently 
associated with pericarditis. It is probable that the occurrence of pneu- 
monia is the result of an independent infection. The occasional occur- 
rence of tonsillitis at the outset of acute articular rheumatism is con- 
sidered by some as evidence of the infectious origin of the latter. Iritis, 
nephritis, and cystitis are rare complications. 

Cerebral complications are sometimes so conspicuous as to give rise to 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



65 



the term cerebral rheumatism. Restlessness, delirium, convulsions, and 
coma may rapidly develop with subsidence of the joint-inflammation, 
usually during the second week, and he associated with hyperpyrexia 
and rapid pulse, the temperature even exceeding 110° F. The hyper- 
pyrexia may prove the cause of death and no abnormal appearances be 
found in the brain. Various mental disturbances may occur during the 
course of rheumatic fever, in mild or severe cases, at the outset or during 
convalescence. The patient may be delirious, even maniacal, with sui- 
cidal intentions, or suffer from melancholia. Hemiplegia from cerebral 
embolism is a rare complication. Chorea, especially in children, some- 
times occurs after the subsidence of the acute symptoms. Attacks of 
chorea may alternate with attacks of rheumatism, and many cases of 
chorea occur in persons who have suffered from rheumatism. A rheu- 
matic neuritis of nerves in the vicinity of the inflamed joint may develop, 
and pain, numbness, or prickling follow. The muscular atrophy which 
sometimes follows a rheumatic inflammation of the joint is occasionally 
attributable to the associated neuritis. 

A variety of cutaneous eruptions may arise. Most frequent are 
sudamina during the stage of excessive sweating, but urticaria, erythema, 
pemphigus, and purpuric spots have been seen. The purpuric spots in 
rheumatic fever should not be confounded with the rheumatic symp- 
toms in purpura, the further consideration of which is to be found in 
the article on Purpura. That the disease is rather rheumatic than pur- 
puric is to be inferred from the extent and severity of the articular 
inflammation and the relief derived from antirheumatic treatment. At- 
tention has been called, particularly of late years and most recently by 
Futcher, to the presence of subcutaneous nodules, first especially described 
by Jaccoud as occurring in infants and young children, and regarded by 
some as pathognomonic of this disease. They appear during the progress, 
or more frequently towards the end, of the rheumatic attack as sharply 
defined nodules of the size of peas. They are few or many, and are 
situated upon the tendons and ligaments, especially near the elbow and 
knee, and upon the pericranium and periosteum. They may rapidly 
develop, disappearing in the course of a few weeks, or remaining for 
months. They are to be found in mild or severe cases, and may appear 
in the absence of inflammatory symptoms. 

Diagnosis. — Acute articular rheumatism is usually readily recognized 
from the grouping of the symptoms. Difficulty is sometimes experienced, 
especially among children, in discriminating between acute osteomyelitis 
and acute articular rheumatism, particularly when the former is multiple 
or in the vicinity of the large joints. The intensity of the pain, the 
extreme sensitiveness of the bone, and the typhoidal symptoms are of 
especial importance in the diagnosis of osteomyelitis. Secondary inflam- 
mations of the joints occurring in the various infectious diseases are 
preceded by the characteristic symptoms of these diseases. In gouty 



66 



GENERAL DISEASES. 



arthritis the small joints, especially the great toe joint, are usually af- 
fected ; pain and redness are more considerable ; sweating is absent ; the 
fever is slight. 

Prognosis. — Acute articular rheumatism generally terminates favor- 
ably, although recurrences even after the lapse of years are frequent, 
and chronic articular rheumatism may result. Eecurrent attacks of 
acute rheumatism may be as severe as the original attack. The mortality 
is estimated at three per cent., the fatal cases being usually due to the 
complications enumerated. 

Treatment. — In acute rheumatism the patient should be dressed in 
a flannel night-dress (which should be so made that it can be frequently 
changed without exposure to the patient), and should sleep between 
blankets and be carefully protected from draughts of air. In most cases 
the diet should be at first restricted to milk, or to barley, oatmeal, or 
other gruels, the food being given in moderate quantities at short in- 
tervals. If milk cannot be borne, broths, raw eggs, and various farina- 
ceous foods may be substituted or given in connection with the milk. 
Mellin's or other similar food is often of service. As the disease pro- 
gresses the diet must be made more sustaining ; but, unless the symptoms 
assume an adynamic type, highly nitrogenous food should be avoided 
until convalescence is assured. 

The affected joints may be wrapped in cotton, or, better, in wool bat- 
ting, and should be kept as quiet as possible by means of sand-bags or 
closely moulded well-fitting splints, but the bandages should never be 
tightly drawn. 

Various local applications to the joints have been employed by prac- 
titioners for the relief of pain, but in our experience they have rarely 
seemed to be effective. The injection of from ten to fifteen minims of a 
one per cent, solution of carbolic acid into a joint from one to three times 
a day has been strongly recommended ; we have had no experience with 
it. Simple warm water, concentrated solution of sodium carbonate (1 
to 10), diluted tincture of aconite, laudanum, saturated solution of am- 
monium chloride, Fuller's lotion (sodium carbonate, six drachms 5 tinc- 
tura opii, one ounce ; glycerin, two ounces ; water, nine ounces), are 
among the most used local applications. In Germany the ice-bag or 
compresses of cold water are much employed. Blisters applied either 
above or below the joint sometimes allay pain and seem to do good ; they 
are, however, especially useful in the advanced stages of the disease, 
when the inflammation lingers after the rheumatie tendency has been 
largely overcome. Under such circumstances their repeated application 
to the joint itself may be essential to a favorable result. 

There are two more or less specific treatments of acute rheumatism. 
The older of these is the treatment by alkaline potassium salts. In 
carrying out the alkaline treatment, one ounce of the potassium salt dis- 
solved in at least one pint of water is to be given during the twenty-four 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



67 



hours in divided doses. As the potassium citrate is converted in the 
system into potassium carbonate, and as it is much less disagreeable to 
the palate and irritating to the stomach than are the carbonates, it 
should always be preferred. Potassium nitrate is very irritant and very 
inefficient. The citrate may be given in a strong lemonade, the lemon 
juice concealing its taste and assisting its action ; or, more agreeably, 
one drachm of the citrate in half an ounce of lemon juice may be put 
into a tumbler for each dose, and diluted at the time of taking with car- 
bonic acid water from a siphon. It is usually necessary after from three 
to seven days to lessen the dose of the potassium salt, on account of its 
depressing influence. 

The salicylic acid treatment is, however, much more effective than 
the alkaline method. The acid itself, sodium salicylate, ammonium sali- 
cylate, or oil of wintergreen may be employed. The acid given in cap- 
sules is the least disagreeable of the preparations, but is so apt to irritate 
the stomach that it can rarely be used with advantage. Sodium salicylate 
is exceedingly disagreeable, and is more depressing, and more apt to nau- 
seate, than is ammonium salicylate j the latter salt is therefore the prep- 
aration which should be ordinarily exhibited. Oil of gaultheria contains 
methyl salicylate in such proportion that one hundred and sixty-nine 
parts of the oil represent one hundred and thirty-eight parts of the acid. 
It affords an excellent method of giving the salicylate, but has seemed to 
us upon the whole more apt to disturb the stomach than the ammonium 
salt, whilst its decided flavor makes it agreeable to some and extremely 
disagreeable to other patients. In some cases it may be combined with 
ammonium salicylate, but in the majority of instances the best results 
are to be obtained by giving the latter salt alone, in milk or in carbonic 
acid water. Twenty grains may be administered from three to six times a 
day. Decided cinchonism should be produced, but its appearance should 
be followed by the reduction of the dose. Delirium and a peculiar dis- 
turbance of the respiratory function, in which the movements become 
very rapid and deep, are spoken of as sometimes caused by the acid, but 
we have never seen them. 

Marked alleviation of the symptoms usually follows salicylic acid tin- 
nitus, but return of the symptoms, or, in other words, distinct relapses, 
are very common. Various opinions are held by authorities in regard 
to the power of small doses of salicylic acid in preventing these relapses ; 
our own opinion is that it is better not to continue the drug in small 
doses, but after a decided result has been obtained to put the patient 
upon alkalies, giving overwhelming doses of the salicylates whenever 
symptoms of relapse occur. We have seen apparently excellent results 
from the continuous local application of the salicylates, especially of oil 
of gaultheria, to the inflamed joints. It is probable that under these 
circumstances sufficient absorption takes place to specifically affect the 
part. Salol, which has been commended, must, in order to be effective, 



68 



GENERAL DISEASES. 



be broken up by the intestinal alkaline juices, and is therefore uncertain 
in its action. Moreover, it contains about thirty-six per cent, of carbolic 
acid, so that if enough is given to produce a full salicylic influence there 
is danger of carbolic acid poisoning. It is therefore unfit for use in acute 
rheumatism. Salicin is a very feeble preparation, probably dependent 
for any influence upon its conversion into salicylic acid in the system, 
and is evidently to be condemned. 

Antipyrin (ten grains) and antifebrin (five grains), two or three times 
a day, are alleged by various practitioners to have a specific influence like 
that of salicylic acid, and probably whatever power they may have is 
shared by phenacetin. These drugs are, however, much less efficacious 
than the salicylate, and are certainly fully as depressing. In obstinate 
cases, however, they may be tried. 

Potassium iodide is sometimes used, but has seemed to us of very 
little value. Colchicum has been effective only when given in such large 
doses as to produce purgation. Quinine has no specific action, but is 
often of service when free sweating and evidences of weakness are mani- 
fested in persons who have been reduced by alkaline or salicylate treat- 
ment. 

Violent cerebral symptoms are said sometimes to be present in rheu- 
matism without high temperature, as the result of brain congestion. In 
all cases which we have seen, however, the nervous symptoms have 
depended solely upon the high bodily temperature, and have subsided at 
once upon the immersion of the patient in a cold bath and the subse- 
quent reduction of temperature. Whenever the temperature is 108° F. 
or above there should not be the slightest fear in the use of the cold bath. 
The subsidence of the nervous symptoms under the use of external cold 
has been in our experience followed by the immediate return of the joint- 
inflammations, which had previously disappeared. 

GONORRHCEAL RHEUMATISM. 

A title applied to the occurrence of symptoms and lesions resembling 
those occurring in acute articular rheumatism, but due to gonorrhoea! 
infection. The probability of various bacteria being concerned in the 
etiology of many cases of acute articular rheumatism has already been 
mentioned, and the frequency of the occurrence of rheumatoid symptoms 
in various infectious diseases has been stated. Especial importance is to 
be attached to the occurrence of such symptoms from infection by gono- 
cocci, from the close resemblance which they bear to the symptoms 
occurring in rheumatic fever. 

Etiology. — That gonococci are the cause of the rheumatoid lesions 
is suggested by the repeated recognition of their presence in the fluid 
from inflamed joints, as shown by Petrone and Kammerer, and in the 
pus from tendon-sheaths, and by their presence in the diseased valves in 
acute ulcerative endocarditis (Leyden), and their discovery by Council- 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



69 



man in myocardial abscesses. Osier records that gonococci were culti- 
vated from the blood of a patient with malignant endocarditis, and others 
have reported the presence of gonococci in the blood. Although the 
gonococcus alone may produce the lesions found in certain cases, other 
bacteria may also be concerned, and it is maintained by some that gonor- 
rhoea! rheumatism represents the accidental concurrence of acute articular 
rheumatism and gonorrhoea. Men are oftener affected than women, and 
urethral or vaginal gonorrhoea is the usual means of infection. Gonor- 
rhoea! ophthalmia and vulvo- vaginal catarrh in infants and children may 
also be followed by gonorrhceal rheumatism. It is stated to occur in two 
per cent, of the cases of gonorrhoea in adults, and may arise during the 
acute stage of the disease, although more frequently some weeks after the 
infection, and it may appear in gleet. 

Morbid Anatomy. — The lesions closely resemble those found in 
rheumatic polyarthritis. The fluid, although thin, contains more pus- 
corpuscles, and the adjoining bursas and tendon- sheaths may become 
inflamed. The large joints are especially liable to be affected, the 
knee-joint being diseased in nearly three-fourths of the cases. One 
or many joints may be inflamed. 

Endocarditis sometimes results, and may present the characteristics 
of a malignant endocarditis. Gonococci alone are to be found in the 
diseased valves, or other bacteria may be present. The aortic valves are 
said to be more often diseased than the mitral. 

Symptoms. — There is no essential difference between the symptoms 
of acute articular rheumatism and those of gonorrhceal rheumatism, with 
the exception that in the latter they are less severe and more obstinate. 
This relation may in part be due to the fact that fewer joints are usually 
simultaneously affected. The disease may be indicated by fleeting pains 
in the vicinity of the joints without fever, or by moderate redness, swell- 
ing, and pain of one or more joints, with slight elevation of temperature. 
In other cases sudden inflammation of the joint occurs with severe pain 
and marked swelling, especially in the knee-joint, but with moderate 
fever. The symptoms usually extend over a period of weeks or months, 
with exacerbations and remissions and possible complications, as endo- 
carditis, pericarditis, pleurisy, or enteritis. The local inflammations 
ordinarily terminate in resolution, but when suppuration takes place 
adhesions may occur, with permanent deformity. The prognosis is gen- 
erally favorable, even when endocarditis is associated. If the pyjemic 
symptoms of ulcerative endocarditis arise, the prognosis becomes grave. 

Diagnosis. — A gonorrhceal cause may be assumed for the rheumatic 
symptoms provided a recent infection has occurred. In obscure cases of 
gleet a gonococcal cause for the rheumatic symptoms may be overlooked. 
In general, fewer joints are affected in gonorrhoea! rheumatism, the fever 
and pain are less extreme, the swelling persists longer, and antirheumatic 
treatment is of but little avail. 



70 



GENERAL DISEASES. 



Treatment. — The treatment of gonorrhoeal rheumatism is very un- 
satisfactory. We have never found the salicylates, colchicum, the iodides, 
or the mercurials to exert a distinct influence for good. In the acute 
cases, rest, fixation of the joints by splints, and blisters or the applica- 
tion of the thermo- cautery over the joints constitute the major part of 
the treatment. 

In chronic cases, careful attention to the general health, the best pos- 
sible hygienic surroundings, the administration of tonics and of arsenic, 
and the use of massage and passive movements, comprise about all that 
can be done by the physician. The utmost importance should always 
be attached to the local treatment of the genito-urinary organs ; the 
obstinacy of the disease often depends upon the existence of a slight 
chronic gleet. The surgical treatment of the inflamed joints, by open- 
ing and irrigation, is said to have yielded satisfactory results. 

CHRONIC ARTICULAR RHEUMATISM. CHRONIC RHEUMATIC 

ARTHRITIS. 

Definition. — A disease of obscure etiology characterized by stiff and 
painful joints. 

Etiology. — Although chronic articular rheumatism may result from 
severe, protracted, or recurrent attacks of acute articular rheumatism, it 
usually presents no obvious relation to the latter condition. It occurs 
chiefly among the poor, especially among those living or working in cold, 
damp places. It is most frequent in adults after middle life. Men are 
more often affected than are women. It occurs at all seasons of the year. 

Morbid Anatomy. — The capsule of the joint is thickened, and 
adhesions are formed between it and the surrounding structures. The 
synovial membrane is thickened, vascularized, spreads over the cartilage, 
and adhesions form between the opposed surfaces. The articular cartilage 
is in part absorbed, and the articulating bones may become anchylosed, 
even consolidated, as is seen in the fusion of vertebrae. 

Symptoms. — Stiffness and pain in the diseased joint are the conspicu- 
ous symptoms. Swelling is usually but trifling. The stiffness is more 
marked in the early part of the day or after rest during the day, while 
pain is complained of on motion, or becomes persistent towards evening. 
The stiffness and pain are often more severe in wet weather. Acute ex- 
acerbations of the inflammation of the joint may occur, associated with 
slight elevations of temperature, compelling temporary rest. The longer 
the inflammation persists the more likely are the joints to creak on 
motion, and the degree of motion is more and more impaired. The 
extremities are flexed in various degrees, the rigidity is only partially 
overcome by passive motion, and in extreme cases the patient is bed- 
ridden because of the rigidity of the joints. Atrophy of the muscles 
follows, and the sufferer is often extremely emaciated. Several joints, 
both large and small, are usually affected, and complete disappearance 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



71 



of the symptoms from a diseased joint is rare. Complications are in- 
frequent. 

Diagnosis. — The method of development of the symptoms of chronic 
rheumatic arthritis is sufficiently characteristic to enable the diagnosis 
to be made in most instances. Gouty arthritis is easily excluded by the 
history of the case, the absence of acute attacks in the great toe joint, 
and the usual polyarticular affection. The sometimes difficult differentia- 
tion from rheumatoid arthritis will be considered in the article on that 
subject. 

Prognosis. — The disease usually lasts throughout life, although for a 
long time the symptoms may be comparatively slight. Temporary im- 
provement is likely to follow the occurrence of exacerbations. 

Treatment. — Whenever in chronic rheumatism it is attainable, the 
subject should live in a mild, equable, dry climate, such as is found in 
Texas and other parts of the dry belt which runs northward from San 
Antonio and in certain parts of Southern California ; if this be not pos- 
sible, he should be most carefully protected from damp, from changes 
of temperature, and from the vicissitudes of the weather. The gen- 
eral bodily health should be assiduously maintained by careful manage- 
ment of the digestive organs, and by the abundant use of nutritious, 
especially of fatty and farinaceous, articles of food, and, whenever prac- 
ticable, of cod- liver oil. The salicylates, the iodides, and the various 
alkaline carbonates may be used from time to time to subdue exacerba- 
tion, but the chief reliance must be upon the use of various baths, as in 
chronic gout. 

The treatment of the joints by massage, and by the application of 
blisters, of ichthyol ointment, of mixed mercurial and belladonna oint- 
ment (equal parts), of oil of gaultheria, of weak alkaline solutions, and 
of other local remedies, is very important. In our experience good has 
chiefly been produced by massage and counter-irritation. 

ARTHRITIS DEFORMANS. RHEUMATOID ARTHRITIS. RHEUMATIC 

GOUT. 

Definition. — A chronic progressive inflammation of the joints char- 
acterized by alterations of the capsule, cartilage, and bone. 

From the resemblance which the symptoms in certain cases of arthritis 
deformans bear to those of chronic articular rheumatism, and from the fact 
that the former disease in rare instances follows the latter, it is probable 
that in such cases the etiology is the same. Frequently there is no such 
sequence, and the exciting causes are usually unknown. From the fact 
that severe destruction of the tissues of the joint and spontaneous dislo- 
cations follow injury and disease of the spinal cord, and that in rheu- 
matoid arthritis the disease is frequently symmetrical and associated 
with hyperesthesia, paresthesia, and disturbances in the nutrition of the 
skin, hair, and nails, a neuropathic origin has been considered probable. 



72 



GENERAL DISEASES. 



The disease usually begins in adult life, but becomes pronounced after 
middle life. In rare instances it may be found in young children. It is 
more frequent in women than in men, and heredity, hardship, and mental 
strain are of etiological importance. The disease may affect one or more 
joints : the monarticular form has directly followed injury to the joint. 
From its frequent occurrence among the poor, and from a certain re- 
semblance in its symptoms to those occurring in gout, it has been called 
"poor man's gout." 

Morbid Anatomy. — Few or many joints may be affected, the larger, 
as the knee, hip, shoulder, and elbow, being oftenest diseased, although 
those of the hands and feet not infrequently first suffer. The vertebral 
joints sometimes show a marked degree of alteration. In extreme cases 
the capsule and ligaments become thickened, and the synovial membrane 
forms a series of fringes, at times transformed into polypoid excrescences, 
in which fibrous and fat-tissue may be found, and which when detached 
form free bodies. The synovial fluid is usually diminished, though 
sometimes it is in excess. The articular cartilage becomes fibrillated 
and softened, and cartilaginous outgrowths project beyond the edge, 
forming fungoid excrescences, sometimes of considerable size, portions of 
which may also become detached and form free bodies. The cartilage is 
also destroyed in places, especially in those exposed to the greatest fric- 
tion. The surface of the bone is laid bare, and is transformed by sclerosis 
into an ivory-like material, — eburnation. In other parts absorption or 
new formation of the bone takes place, the latter perhaps extending into 
the cartilaginous excrescences, and extreme deformity of the joint results. 
Absorption of the bone may cause a nearly complete disappearance of 
the head of the femur or of the humerus, and the vertical diameter of the 
vertebrae may be shortened. The vertebrae may be thus consolidated by 
the union of bony excrescences from the contiguous surfaces. Partial 
dislocations are frequent, and especially at the hip a false joint may be 
formed at some distance from the acetabulum. The tendons near the 
affected joint may become thickened and the muscles atrophied, perhaps 
fibrous. Lateral bending of the fingers towards the ulnar surface of the 
hand frequently occurs, and the great toe may be inclined towards the 
little toe. 

Symptoms. — The disease usually develops slowly, beginning in a few 
joints, but extending in the course of years to many, with variations in 
the severity of the process. The first symptom is usually impaired mo- 
bility of the affected joint or joints, especially on rising or after prolonged 
rest. The incipient stiffness of the joint is relieved by exercise, but is 
increased as the joints become painful. The pain varies in degree, or- 
dinarily being well borne, although sometimes very severe. Temporary 
exacerbations of the inflammation lasting a few days often occur, during 
which there may be slight swelling and tenderness of the joints. With 
the progress of the deformity motion becomes more impaired, and is as- 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



73 



sociated with creaking, but is never absolutely restrained, although ex- 
treme flexion of the thigh, leg, and forearm may occur. The extreme 
impairment of motion occurs in the vertebrae, which when consolidated 
form a rigid spine. There is no elevation of temperature, except a slight 
rise during the acute exacerbations. 

Closely allied are the arthropathies following injury to the nerves and 
spinal cord and occurring in locomotor ataxia and poliomyelitis. Their 
course, however, is rapid and usually painless, and, although associated 
with growth of the synovial membrane, is characterized by extensive 
destruction of the cartilage and absorption of the bone. 

Another affection of the joints closely allied in its results to rheuma- 
toid arthritis is the malum senile, or, from its frequent localization, morbus 
coxae senilis. It is found exclusively in old people, and consists in fibrilla- 
tion, softening, and destruction of the cartilage, absorption and eburnation 
of the bone, and corresponding deformity of the joints. Cartilaginous 
outgrowths are lacking, and the capsule of the joint becomes indurated. 
The pain is moderate. There is no tenderness, and the motion of the 
joint is usually lessened, although sometimes exaggerated, and is accom- 
panied with creaking. 

Diagnosis. — The symptoms of rheumatoid arthritis are usually suffi- 
cient to permit the diagnosis to be made. During the earlier period of 
its development it cannot always be differentiated from chronic articular 
rheumatism. In the progress of the two diseases the former results in 
more extensive deformity of the joint, but without complete obliteration 
of its functions. Persistent chronic articular rheumatism tends towards 
anchylosis of the joint. Eheumatoid arthritis generally is limited to 
few and large joints ; chronic rheumatic arthritis affects many and sym- 
metrical joints. 

Prognosis. — Although the disease may come to a stand-still in its 
earlier stages, complete recovery does not occur. As a rule, the disease 
progresses, extends from joint to joint, and persists throughout the life 
of the patient, who may attain an old age. 

Treatment. — In arthritis deformans, whenever it is possible, the 
patient should live in a dry, warm, equable climate ; when this is not 
possible, every effort should be made by proper clothing to protect against 
damp and cold. The diet should be abundant and nutritious. Tonics 
and other drugs may be used to meet the symptoms as they arise, but 
the only remedies which seem to have influence upon the disease are 
iodine, preferably in the form of potassium iodide, and arsenic, which 
should be commenced in small doses and kept up continuously for 
months in ascending doses, great care being taken not to derange the 
digestion. The salicylates are sometimes useful in an acute exacerbation. 
Cod-liver oil is of great importance when there is a tendency to emacia- 
tion and loss of strength. 

There can be no doubt as to the value of careful massage in affecting 



74 



GENERAL DISEASES. 



inflammatory exudations, and in combination with Swedish and other 
gymnastic movements in maintaining the mobility of the joints, the 
general health, and the nutrition of the muscles. Baths are very much 
used, especially sulphur baths ; and annual resort to sulphur springs (in 
this country Sharon, Eichfield, and the various sulphur springs of Vir- 
ginia) often greatly protracts life and conduces to comfort. Hot salt-water 
baths are sometimes useful, and Striimpell very strongly recommends hot 
sand-baths. Counter-irritation over the joints by means of blisters or 
iodine may be exceedingly useful, but must be tried with caution. 

MUSCULAR RHEUMATISM. MYALGIA. 

Definition. — Attacks of pain referred to certain muscles or to the 
tendons and fascia with which they are connected. 

Etiology. — The term muscular rheumatism is largely one of con- 
venience, it being probable that various affections have thus been desig- 
nated. In certain cases a wry neck will immediately follow a tonsil- 
litis, and the same infection is the presumable cause of both. The act 
of stooping may be followed by a tearing sensation in the lumbar region, 
and severe pain follow not differing from that occurring in a person 
whose back is exposed to a draught of air. To the latter condition 
alone is the term muscular rheumatism strictly applied. Its use should 
be more especially limited to muscular pains which are independent of 
any obvious anatomical lesion of the affected region or of any unquestion- 
able cause. On the one hand, it is considered that exposure to cold and 
wet and the rapid cooling of a heated perspiring skin are exciting causes, 
a view which is favored by its more frequent occurrence among laboring 
men and, at times, in sufferers from chronic articular rheumatism ; on the 
other hand, it has been regarded as a neuritis of the sensitive nerves of 
the affected region. 

Symptoms. — Pain is the conspicuous symptom, and may be a dull 
ache, or a piercing or tearing pain. It is aggravated and may become 
insupportable on motion of the muscles concerned, and may be relieved 
when they are relaxed, thus compelling the patient to assume the most 
extraordinary positions from the rigid contraction of the antagonistic 
muscles. The pain may be increased or relieved by pressure. It is un- 
accompanied by swelling, although an appreciable rigidity of the muscles 
is sometimes felt, and fever is absent. Single muscles or groups of muscles 
may be affected, and the myalgia may shift from one part to another. 
According to the localization of the pain various terms are applied, as 
torticollis, stiff- or wry-neck, in which case the sterno- mastoid and some- 
times the trapezius are the seat of the disturbance, lumbago, when the 
muscles of the loin and their attachments are concerned, pleurodynia, 
the pectoral and intercostal muscles being involved, omodynia, with in- 
volvement of the scapular group of muscles, and cephalodynia, when the 
occipito-frontalis is affected. 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



75 



A distinction is drawn between acnte and chronic myalgia. The 
former is more likely to resnlt from unknown infection or a single ex- 
posure to a draught of air. It may be accompanied with slight fever, and 
usually continues but a few days. Chronic myalgia is rather the result 
of repeated or prolonged exposure, lasts several weeks, and shows a 
tendency to recurrences. In such cases fibrous thickenings of the mus- 
cles have been found, especially in elderly people who have suffered from 
frequent recurrences perhaps continued over a period of years. 

Diagnosis. — This affection is usually easily recognized by the known 
exposure and the nature of the attack. Myalgia is to be distinguished 
from neuritis, which is limited to the course of the nerve. The nerve 
when inflamed is sensitive to pressure as it nears the surface of the body 
or overlies bony prominences, but is commonly unaffected by muscular 
action. 

Torticollis is relieved by friction, and does not become insupportable 
on motion as does cervical spondylitis, which is tender to the touch. In 
lumbago the absence of fever excludes the backache of acute infectious 
diseases, and the examination of the urine and of the pelvic contents 
permits the exclusion of renal, rectal, uterine, or ovarian disease. Its 
usual brief duration enables inflammatory or neoplastic disease of the 
subjacent parts to be differentiated. Pleurodynia may be confounded with 
intercostal neuralgia, but sensitive points are lacking. Caries of the rib 
produces a tender as well as painful swelling, and pleurisy is character- 
ized by physical signs. The pain from muscular rheumatism of the 
abdominal muscles may bear a slight resemblance to that of peritonitis, 
but the characteristic symptoms of the latter disease rapidly develop. 

Treatment. — A severe acute attack of muscular rheumatism can 
often be immediately relieved by a free sweating. (For method of pro- 
duction, see Influenza, page 160.) The local application of heat by means 
of hot- water bags or sand-bags is often of service. Local blood-letting 
by cups or leeches will usually bring great relief. Blisters are even more 
powerful, but only in rare instances is such heroic treatment necessary. 
Sinapisms and irritating liniments are often useful. The application of 
a rapidly interrupted faradic current is frequently effective, especially 
after the subsidence of the first acute symptoms. The salicylates given 
for a few days in large doses (preferably ammonium salicylate) in rheu- 
matic cases will generally produce an immediate cure. In protracted 
cases, with a marked tendency to recur, the basal condition is ordinarily 
gouty, and a more or less rigid application of the rules of treatment for 
chronic gout will usually be effective. Localized myositis of a non- rheu- 
matic character sometimes occurs, and is scarcely to be distinguished 
from a rheumatic myositis : such a case would not, of course, yield to anti- 
rheumatic remedies, but should be treated by means of counter-irritation. 
When with a myositis, whether of rheumatic or of other origin, marked 
contraction of the muscles occurs, as in wry-neck, the one-hundredth of 



76 



GENERAL DISEASES. 



a grain of atropine sulphate should be injected directly into the muscle 
itself ; severe pain may be immediately relieved by the addition of mor- 
phine sulphate to the atropine. 

GOUT. ARTHRITIS URATICA. ARTHRITIS URICA. 

Definition. — A constitutional affection characterized by inflam- 
matory and degenerative changes in various organs and tissues of the 
body, especially in the joints, associated with the deposition chiefly of 
sodium urate and by various disturbances in the functions of numerous 
organs. 

Etiology. — Our knowledge of the pathological processes concerned 
in the causation of gout is but elementary. Numerous hypotheses have 
been offered, but none give satisfaction. The discovery by Garrod of 
uric acid in the blood in cases of gout led to the view that the formation 
of an excess of uric acid and its deposition in the tissues were the essential 
features of gout. He observed that there was a diminished elimination of 
uric acid during and an increased formation after the close of the attack 
of gout. The causes of such excessive formation were not ascertained. 
Garrod assumed that there was a diminished elimination of uric acid by 
the kidneys, and that in consequence of a lessened alkalinity of the fluids 
a precipitation of the urates was accomplished ; while Roberts asserted 
that a relatively insoluble biurate was formed from the excess of uric acid 
in the blood. Pfeiffer maintains that there is no such excessive formation 
of uric acid in gout, and that the important characteristic is the presence 
of modifications of uric acid soluble with difficulty in various organs and 
tissues, therein practically agreeing with the view of Roberts. Charcot 
suggested that an increased formation of uric acid takes place in gout in 
consequence of hepatic disturbance, and Cantani, Ebstein, and Senator 
consider that there is an increased formation of uric acid in various tis- 
sues and organs of the body. Horbaczewski, however, asserts that uric 
acid is formed from the nuclein of the white blood-corpuscles, and Yon 
Noorden states that the elimination of uric acid in gout is not essentially 
different from that in health. 

Of importance in the origin of gout is heredity, a tendency to this 
disease having existed in many families through centuries. Hutchinson 
observed that the younger children were more prone to typical gout than 
the elder, and that the inherited tendency was more often transmitted by 
the father than by the mother. It has been suggested in explanation of 
these observations that the manifestations of gout usually appear towards 
the close of the child-bearing period, and hence the older children are be- 
gotten and born before active gout exists in the parents. Although the 
symptoms of gout appear most frequently in middle life, rarely young 
children may be affected. Men are more often diseased than women, 
especially wealthy persons of sedentary habits living in luxury, although 
those suffering from poverty and hardship are not exempt. The disease 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



77 



affects rather the fat than the lean, and is not infrequently associated 
with glycosuria. 

Of especial importance in the production of gout are the habits of 
the individual. The free use of alcoholic drinks, especially port, ma- 
deira, sherry, burgundy, champagne, ale, and porter, is often the ex- 
citing cause. The prevalence of gout in England, France, Holland, and 
Germany is attributable to the frequent use of these beverages, while 
in the United States, where strong wines, ale, and porter are not in 
general use, typical cases of gout among the native-born are rare. 
The abundant use of red meat has generally been regarded as an exciting 
cause, but recent investigations (Pfeiffer) tend to disprove the correct- 
ness of this view. The relation between lead poisoning and gout to 
which Garrod calls attention has been both advocated and disputed. 
Eecent as well as early observations in France, England, and America 
confirm those made by Garrod as to the occurrence of typical attacks 
of gout in cases of lead poisoning independently of the usual exciting 
causes. The rarity of gout among lead- workers in this country sug- 
gests that exposure to lead alone is not a sufficient cause. The imme- 
diate attack may be induced by alcoholic or sexual excess, mental 
excitement or depression, exposure to cold, or injury. The usual local- 
ization in the great toe joint is attributed to its frequent exposure to 
injury and its comparatively feeble circulation. Garrod observed that 
in persons who had previously suffered from rheumatism the rheumatic 
joints were the first to be attacked with gouty inflammation, and Charcot 
found that in a gouty paralytic the joints conspicuously affected were 
those of the paralyzed side. 

Morbid Anatomy. — The changes characteristic of gout are found 
within and in the vicinity of the joints, especially of the metatarsopha- 
langeal joint of the great toe. The synovial membrane is thickened and 
villous. A chalk-like deposit of urates, especially sodium urate, takes 
place in the capsule of the joint, its cartilages and ligaments, and eventu- 
ally in the neighboring tendons, fasciae, bursse mucosa, periosteum, and 
bone. The cartilage becomes fibrillated. The alterations of the joints 
are more frequent in those of the hands and feet, although the larger 
joints are not spared. The chalky masses in the vicinity of the joints 
are called tophi, and may be as large as the tip of the finger. Tophi are 
also formed in the auricular cartilages, more rarely in the cartilages of 
the nose. Pfeiffer regards Heberden's nodules, the rounded knobs of 
bone projecting from the second and third phalanges, as a result of gout, 
maintaining that, although these may be found in persons who have had 
no attacks of gout, the urine of such patients has the gouty character- 
istics. He also asserts that in chronic articular rheumatism the joints 
above mentioned are unaffected. In chronic gout the kidneys are fre- 
quently in a state of fibrous atrophy, the urates being deposited both in 
the pyramids and in the cortex. Hypertrophy of the heart is associated 



78 



GXENEEAE DISEASES. 



with this gouty kidney, and coronary sclerosis, fibrous myocarditis, and 
chronic endocarditis, especially of the aortic and mitral valves, are of 
frequent occurrence. Gastro- enteric catarrh, inflammation of the serous 
membranes, and pneumonia are frequent complications. 

Symptoms. — Gout is conveniently divided into the articular and 
visceral varieties. Articular gout is primary, typical, acute, or chronic, 
while visceral gout is atypical and chronic in character. Acute articular 
gout or gouty arthritis occurs in the form of attacks which are usually 
recurrent, the intervals being long or short, separated by months or 
years, and the attacks are preceded by digestive disturbances, muscular 
pains, headache often severe, chilly sensations, slight elevation of tem- 
perature, and scanty urine of high specific gravity with a lateritious 
sediment. In the course of a number of days, usually after midnight, 
the patient is aroused by a sudden attack of severe pain of a boring 
character, oftenest in the metatarso -phalangeal joint of the great toe, — 
podagra. More rarely other joints may be involved, either the small 
joints of the feet or hands, or the knee, hip, shoulder, or elbow joint. 
The affected joint becomes red, swollen, and tender, and its superficial 
blood-vessels are congested. The temperature rises three or four degrees, 
and the pulse is moderately accelerated and at times irregular. The pain 
diminishes towards morning, and during the day the inflamed joint is 
comparatively comfortable, the relief to the pain being associated with 
lowering of the temperature and a sour perspiration, although the diges- 
tive disturbances, especially an acid stomach, constipation, or diarrhoea, 
are present. A recurrence of the pain and other symptoms takes place 
during the successive nights for a week or more, the severity of the 
symptoms gradually diminishing as the attack ceases. The redness, 
heat, and swelling of the joint disappear, the skin itches, and the epi- 
dermis over the inflamed joint separates in scales. The premonitory 
diminution in the flow of urine persists throughout the attack, and there 
is a diminished secretion of uric acid, while the blood contains an excess 
of urates. In the intervals between the attacks the flow of urine increases 
and an excess of uric acid is formed. The presence of uric acid in the 
blood may be determined by the method suggested by Garrod. From one 
to two drachms of blood- serum obtained by venesection or wet- cupping 
are placed in a watch-glass with a few drops of acetic acid. A thread is 
placed in the mixture and allowed to remain for twenty-four hours, at 
the end of which time crystals of uric acid are seen attached to the 
thread. A like result occurs if serum obtained from a blister is used 
instead of that formed in the clotting of blood. 

In chronic articular gout the attacks are of longer duration, although 
less severe, and numerous joints may be diseased. This variety may be 
chronic from the outset, especially in debilitated persons. Permanent 
deformity of the joints results, evinced by persistent thickening of the 
tissues, the formation of tophi, partial dislocation, and muscular atrophy. 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



79 



The skin overlying the tophi may become ulcerated, and a watery dis- 
charge escapes containing chalk-like granules composed of acicular crys- 
tals of sodium urate. The resulting fistulous ulcers may heal or extend 
into the joint, and in extreme cases the phalanges of the fingers and 
toes may become detached. 

The term visceral gout is applied when persons of gouty antecedents 
or those suffering from chronic articular gout are affected with chronic 
catarrhal affections of the various mucous membranes, especially of the 
respiratory, intestinal, and urinary tracts. In them the arterial tension 
becomes increased. Arterio -sclerosis, especially of the vessels of the 
heart and kidneys, often occurs. Symptoms of chronic endarteritis and 
valvular endocarditis, especially at the aortic and mitral orifices, are 
frequent. The heart becomes hypertrophied, interstitial myocarditis is 
often present, and the kidneys atrophy. In the latter case the urine 
is copious, of low specific gravity, and contains a large trace of albumin, 
and occasionally hyaline casts. Fibrous atrophy of the kidney, with 
the deposition of urates in this organ, may occur with normal joints in 
persons of gouty antecedents. Sand, gravel, or calculi of uric acid may 
form, and symptoms of vesical or renal calculi follow. Attacks of mild 
or severe uraemia may result, and fatal inflammation of the serous mem- 
branes, especially of the pleurae and the pericardium, occur. Meningitis, 
diphtheritic enteritis, pneumonia, asthma, eczema, transitory and perma- 
nent glycosuria, keratitis, and iritis are occasional complications. 

The designation metastatic, retrocedent, or retrograde gout is used 
when there is a rapid improvement in the arthritic condition associated 
with severe symptoms of visceral disease. In such cases the gout is said 
to attack the stomach when severe epigastric pain, nausea, vomiting, and 
diarrhoea, followed by collapse, occur. Metastasis is thought to affect the 
heart when palpitation, dyspnoea, and angina pectoris take place. The 
presence of delirium, convulsions, paralysis, or coma is attributed to in- 
volvement of the brain ; while intense sciatica and a sense of constriction 
around the chest or loins suggest a metastasis to the spinal cord. Such 
retrocedent attacks are more likely to occur in chronic gout, are not at- 
tended with the deposition of crystalline urates, but in many cases are 
probably due to coronary sclerosis, cerebral hemorrhage, or uraemia, ac- 
cording to the seat and nature of the manifestations. 

Diagnosis. — Typical attacks of acute gout are unmistakable in virtue 
of their seat and course. Chronic articular gout is easily to be recognized 
provided tophi are present. If they are absent, the history of the earlier 
attacks and the characteristics of the blood and urine may permit the diag- 
nosis to be made. Arthritic tophi when not recognizable as chalky masses 
are to be distinguished from the excrescences of rheumatoid arthritis by 
their frequent superficial seat and less resistance. The recognition of vis- 
ceral gout is based upon the association of the symptoms with evidence 
of articular gout, or upon their occurrence in persons of gouty ancestry. 



80 



GENERAL DISEASES. 



Prognosis. — The attacks of primary arthritic gout are usually free 
from danger, especially when they occur in persons in the prime of life. 
Recurrent attacks are always to he expected, and are not incompatible 
with a long and active life. Chronic gout in elderly and debilitated per- 
sons is a source of danger from the associated weakness and the liability 
to diabetes, pneumonia, cerebral hemorrhage, and incurable disease of the 
heart and kidneys. 

Lithsemia. — This term was introduced by Murchison to characterize 
an assumed condition of the blood attributed to temporary or persistent 
functional derangement of the liver. This derangement was considered 
to be indicated by disturbances of digestion, circulation, and secretion, 
but especially by an excess of uric acid in the urine and the frequent de- 
position of uric acid and urates. Although the symptoms described were 
those often found in gout and in the children of gouty parents, yet they 
might occur in persons wholly free from the suspicion of gout. It was 
Murchison' s view that gout was a result of lithsemia. These symptoms in 
gouty persons were those to which the term gouty dyspepsia, or latent, 
suppressed, anomalous, or irregular gout, was applied. Da Costa has 
recently given increased popularity to the term lithsemia, which is not 
likely to yield to its most recent substitute uric-acidcemia. 

It is recognized that the causes important in producing typical attacks 
of gout are also influential in the production of the symptoms now under 
consideration. These relate primarily to disturbances of digestion, such 
as an irregular appetite, coated tongue, a disagreeable taste in the mouth, 
acid eructations, flatulence, a sensation of epigastric weight and fulness, 
and constipation alternating with diarrhoea. Palpitation of the heart,- and 
a slow, irregular, or intermittent pulse, are frequent. The patient suffers 
from vertigo, occasional attacks of frontal headache, blurred vision, neu- 
ralgic pains, and other disturbances of sensation, and from muscular 
cramps in various parts of the body. The mental condition is likely to 
be affected, the patient being restless, irritable, hypochondriacal, perhaps 
hysterical. The gouty origin of such symptoms may be admitted when 
there is evidence of gout in the joints, or when the cardio- vascular and 
nephritic disturbances mentioned under chronic gout are present, or 
when the symptoms occur in the children of gouty parents. The demon- 
stration of uric acid in the blood by Garrod's test would also be evidence 
in favor of a gouty origin of these symptoms, although an excess of uric 
acid in the blood, the uriccemia of Flint, also exists in leuksemia and 
chlorosis, in which the enumerated symptoms are absent. The presence 
of a lateritious sediment in the urine, to which so much diagnostic im- 
portance is often attached, even Murchison admits may exist for years 
without discomfort. Da Costa, although reiterating the importance of 
the frequent occurrence of high-colored, acid urine with high specific 
gravity and brick- dust sediment in the diagnosis of lithsemia, would 
retain this term even if the urine were of low specific gravity and 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



SI 



without excess of uric acid, the "lithseinic" symptoms in such cases 
being attributed by him to the effects of other products of tissue-meta- 
morphosis than uric acid. 

Lithsemia is, therefore, to be regarded purely as a term of convenience, 
by preference applied to the association of few or many of the symptoms 
above mentioned, with frequent or persistent lithuria in contradistinction 
to the association of these symptoms with calcic oxalate in the urine, — 
oxaluria, — or with a phosphatic sediment, — phosphaturia, — or without 
any sediment whatsoever. When such symptoms occur in persons with 
typical manifestations of gout or with an inherited tendency to this dis- 
ease, they should be regarded as evidence of gout, pure and simple, 
neither u latent' 7 nor " suppressed," but perhaps alternating with or 
eventually to be followed by typical attacks of arthritic gout. 

Treatment. — In the acute gouty paroxysm, large doses of the sali- 
cylates sometimes give relief, as in rheumatism, but are less effective 
than is colchicum ; vinum colchici radicis (ten to fifteen drops) or the 
alkaloid colchicine (dose, one-hundredth of a grain) may be given three 
or four times a day. Antipyrin, antifebrin, and phenacetin are some- 
times useful in allaying the pain. When the patient has already suf- 
fered from repeated paroxysms, depleting or sedative treatment may be 
dangerous, and alcohol, digitalis, and other stimulants may be required. 
Under any circumstances we believe it to be bad practice to attempt to 
shorten very greatly a gouty paroxysm by the use of large doses of col- 
chicum, but it is especially so when the paroxysm takes other form than 
that of a podagra. We have seen fatal metastasis to the alimentary 
canal under such circumstances apparently produced by moderate doses 
of colchicum. 

The non-medicinal treatment of the acute paroxysms of gout consists 
in enforced rest in bed or on a couch, restriction to light diet, and the use 
of mechanical protection to the inflamed joint, which should be kept well 
elevated and wrapped in cotton wool, dry, or saturated with laudanum and 
tincture of aconite if this afford relief. It is usually well to begin the 
medicinal treatment by a free mercurial purge, and during the whole 
course of the attack the bowels should be kept loose by salines or other 
laxatives. Pain should be relieved, but rarely suppressed, by opium, 
aided at night by chloral, trional, or sulphonal to obtain sleep. The 
depurant remedies consist of the alkaline salts of lithium and potassium, 
which may be given in the form of natural mineral waters, which are, 
however, generally of such feeble constitution that they must almost 
universally be artificially reinforced. Moreover, these mineral waters 
have no curative properties other than those of similar artificial prepara- 
tions, their apparent superiority resting chiefly upon the large amount 
of water which is taken with them : so that expense can be saved and 
as good results achieved by the use of artificial alkaline waters made 
of such strength that the patient should take at least a quart a day. 

6 



82 



GENERAL DISEASES. 



A very excellent combination, which is especially useful when there is 
uric acid gravel, is that of formula 4 : the benzoic acid converts the uric 
acid into the soluble hippuric. 

The remedies believed to be directly useful in chronic gout and be- 
tween the paroxysms of acute gout are the alkalies, especially the lithium 
salts, the salicylates, colchicum, and piperazin. Of the lithium salts the 
citrate is the one usually employed (dose, five to ten grains three times a 
day). Colchicum given for a length of time is often very effective. In 
those cases in which colchicum does most good the salicylates are usu- 
ally of little service, and vice versa. Of the salicylates the strontium salt 
is of special value, because it can be given in capsules (five to ten grains 
three times a day) without causing irritation of the stomach ; although 
its influence as a salicylate is slower than that of other salts, it acts 
steadily and persistently. Moreover, it very commonly improves in- 
stead of disordering digestion, and is especially useful when there is a 
tendency to fermentative changes in the alimentary canal with conse- 
quent intestinal flatulence. The long- continued and free use of salicy- 
lates may produce cardiac weakness. Piperazin is believed to act simply 
by rendering uric acid soluble ; in many cases of chronic gout it seems 
to achieve very little, but in some cases when given in large doses (ten to 
fifteen grains three times a day) its influence is marked. The oncoming 
of giddiness and weakness should be the signal for its withdrawal. 

In lithsemia, in chronic gout, and between the paroxysms of a podagra, 
the chief reliance must be upon exercise and the proper regulation of 
the diet. The exercise should be carefully adapted to the strength of 
the individual case, and as the strength increases should be steadily in- 
creased in severity. It should always be sufficiently violent to cause 
free sweating, and should be followed by a bath. In a subject of fair 
degree of power regular training under an instructor is of the greatest 
advantage ; in many cases habitual hard out- door exercise can alone 
secure comfort and health. 

The local treatment of gouty deposits in the muscles and fibrous 
structures and of gouty arthritis is often of great importance. Massage 
may be very serviceable or harmful as it is employed skilfully or unskil- 
fully. Counter-irritation by means of blisters often does great good, but 
requires care in its use. Faradization with a very rapidly interrupted 
current is frequently of great service in gouty myositis of a not too acute 
type ; the continued galvanic current to the gouty joint is recommended 
by some, but we doubt whether it ever does any good. (See also Neu- 
ritis, page 603.) Local hydro-therapeutic treatment is often of great 
value ; water as hot as can be borne thrown very forcibly by means of a 
needle-spray and followed by careful massage is not rarely effective in dis- 
persing local gouty or rheumatic exudations. The application of tightly 
fitting wool coverings, kept on day and night, frequently brings great re- 
lief, especially when the larger joints, such as the knee, are in question. 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



83 



In all classes of gouty patients fresh eggs, milk ? the white meats 
(except pork), chicken, and game, should constitute special articles of 
food. Strong stock soups and alcoholic stimulants are usually to be en- 
tirely forbidden. When in feeble cases alcoholic stimulants are required, 
well- diluted whiskey or other spirit is always preferable to any malt liquor 
or wine. The diet of gouty or lithsemic patients must be various. When 
the subject is robust and vigorous it is highly important to reduce the 
amount of food taken to just sufficient to prevent loss of strength and 
weight. When the nutrition and vital forces are on a very low level it 
may be necessary to urge the taking of more food. When there is a 
great tendency to the accumulation of fat, with robustness of constitution, 
the fat should be largely removed by exercise 5 but there are fat anaemic 
gouty subjects in whom starchy foods must be withdrawn almost as 
rigorously as in the diabetic. The use of cane sugar should be reduced 
to the minimum ; in fatty cases all sweetening except with saccharin 
should be interdicted. Starchy food should always be largely reduced. 
Potatoes should be used very sparingly, if at all. Bread is not to be 
denied, but, at least in part, gluten, bran, or whole wheat bread should 
be used. Most acid fruits and vegetables, such as strawberries, toma- 
toes, sorrel, etc., should be forbidden, but grape-fruit and lemons may 
be allowed, as well as sweet apples, oranges, and grapes. Whenever the 
fruit deranges the digestion it should be withdrawn. In robust acutely 
gouty people red meats should be permitted in small quantities, but in 
feeble chronically lithgemic people should be used freely. When the 
digestion and the strength are good, a diet largely composed of green 
vegetables is often of service. In severe chronic gout or lithsemia, espe- 
cially if there be digestive disturbances, the exclusive milk diet should 
be essayed. From five to seven pints of partially skimmed milk may be 
given daily. Separator milk should never be allowed. The milk should 
always be taken slowly, a mouthful at a time, — warm or cold, but never 
boiled. In most cases in from two to four weeks it is necessary gradually 
to take the patient off the milk diet, but in some instances the best results 
are achieved by a continuance of the milk. We have seen the hardest 
labor performed for months by gouty individuals who were enabled to do 
their work and freed from suffering by restricting themselves to an abso- 
lute milk diet. Any constipation which may be produced must be over- 
come by the daily use of laxative remedies ; in some instances oatmeal or 
other laxative farinaceous foods may be employed with advantage, and 
very frequently their addition to the milk diet should be the first change 
when the latter is being withdrawn. 

In the treatment of chronic gout the use of baths is of the greatest 
importance. Every lithsemic subject should form the habit of taking the 
Turkish bath once a week, even if there be no very pronounced symp- 
toms of the diathesis. Under such practice the glands of the skin become 
habitually active, so that the kidneys are assisted not only by the sweat- 



84 



GENERAL DISEASES. 



ing at the time of the bath, but by the free perspiration which occurs at 
other times. If the Turkish bath be not attainable, ordinary hot baths 
may be used at regular intervals, but under all circumstances the body 
should be sponged down with cold water after taking the hot bath. When 
the lithsemic symptoms are acute, the Turkish bath, the steam bath, or 
the simple hot or medicated water bath, may be used daily, or more fre- 
quently or more seldom according to the needs and strength of the indi- 
vidual. The pine-needle bath, which is made by passing steam through 
the leaves of the Finns sylvestris, is especially serviceable in sciatic and 
other forms of rheumatic nerve disease. In Europe the so-called mud — 
really the peat — bath is much used, and is undoubtedly often effective. 
It is probable that all these medicated baths act rather by increasing the 
excretion from the skin than by any specific influence of their constitu- 
ents, though the sulphur baths may be an exception to this rule. 

The climatic treatment of gout and rheumatism is very important ; 
in many cases the disease can be kept in abeyance after failure of treat- 
ment in a bad climate by removal to some dry, equably warm region, 
such as the interior of Southern California, or the lower part of the dry 
belt which runs from San Antonio, Texas, northward to Colorado Springs. 
In the medicinal treatment of chronic gout it is essential to regulate care- 
fully the action of the digestive organs by the use of such remedies as 
are called for by the symptoms in the individual case. Thus, in plethoric 
gouty subjects with constipation frequent purgation is of service ; on the 
other hand, in feeble subjects with a tendency to gastro-intestinal catarrh, 
silver nitrate, bismuth with carbolic acid, and similar remedies, may be 
required. 

In chronic gout, life may often be prolonged by an annual visit to some 
mineral spring. The good results are largely due to the change of scene, 
freedom from care, and the enforced diet and exercise, but natural min- 
eral waters have some especial value. All springs may be divided into 
the simple hot spring, the alkaline-saline spring, and the sulphur spring. 
There is no reason why better results should be achieved in Europe than 
in America, except in the superior organization of the European health- 
resorts, a superiority which is disappearing year by year. Indeed, the 
mineral springs in Europe do not in their power and variety equal those 
of this continent. There can be no doubt that patients are better suited 
by one class of springs than by another, but we have never been able to 
frame any a priori rules of selection which were entirely satisfactory. 
When in any cases the habit is plethoric, with constipation and other 
evidences of torpor of the hepatic and other glandular apparatus of the 
alimentary canal, the very active saline springs, such as Carlsbad and 
Contrexeville, are especially effective. If in any case the abdominal con- 
dition just spoken of is conjoined with a tendency to weakness, the feebler 
saline springs, such as Wiesbaden, should be preferred. Sulphur springs 
have seemed to us especially useful when the joints are largely affected or 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



85 



when there is a marked tendency to anseinia and weakness. In any 
individual case, however, experience is the most important guiding prin- 
ciple, and the different springs may be tried at different times until one 
is found to be especially effective. When there is an anaemic tendency, 
excellent results are obtained by following the course of saline waters 
by residence at a ferruginous spa. 

DIABETES MELLITUS. 

Definition. — A chronic disease characterized by the persistent pres- 
ence of sugar in the urine, and, in severe cases, by an increased flow of 
urine, excessive thirst, digestive disturbances, and progressive loss of 
flesh and strength. 

Sugar is always present in the blood and lymph, and Baumann has 
shown by means of delicate tests its constant presence in normal urine. 
Such sugar is in part absorbed directly by the intestine, but more largely 
results from the transformation into glucose of the carbo-hydrates, and to 
a less extent of the albuminous constituents, of the food. Such trans- 
formation is effected by the pancreatic and intestinal juices, and the 
glucose is absorbed by the portal vein. If more is absorbed than is 
needed for the immediate performance of the functions of the body, the 
excess is stored as glycogen in the liver and muscles, to be subsequently 
utilized when needed, and the remainder is transformed into fat. Some 
of the sugar in the blood may also be formed in the muscles. An ex- 
cess of sugar in the blood may thus result from the increased supply of 
sugar or sugar-forming food in the diet, when an alimentary or dietetic 
glycosuria results, ceasing upon attention to the diet. An excess may 
also result from the failure on the part of the body to decompose or store 
that which is introduced. This may be due to a disturbance of the portal 
circulation dependent upon faulty innervation of the blood-vessels or to 
disturbances in the function of the liver, in consequence of which more 
glucose enters the blood without being transformed into glycogen in the 
liver, or an excessive transformation of glycogen in the liver takes place, 
setting free an excessive amount of sugar. (For the further considera- 
tion of this subject see Melituria.) 

Etiology. — Diabetes is a disease most frequently found in middle 
life, although it may occur in children and, very rarely, in infants. It 
is more common among men than among women, and heredity often 
appears of importance. All authorities recognize its considerable fre- 
quency among Jews. Syphilis and gout are generally considered as of 
etiological importance. Grube states that in one hundred and seventy- 
seven cases gout or ancestral gout was of frequent occurrence. Fat 
persons appear predisposed, and Cantani assigns importance to the ex- 
cessive use of sweetened food and drink. 

The importance of affections of the nervous system in the production 
of diabetes is shown in the frequency with which shocks and strain of 



86 



GENERAL DISEASES. 



the nervous system are immediate antecedents. In like manner injuries, 
especially those to the head, cerebral hemorrhage, and tumors of the 
brain, insanity, epilepsy, and hysteria, also locomotor ataxia, are at 
times intimately connected with diabetes. In a number of cases diabetes 
has so immediately followed an acute infectious disease and exposure to 
cold that these have been considered as of etiological importance. 

Disease of the pancreas has been found, especially of late years, to be 
of importance in the etiology of diabetes. Cowley in 1788 first noted 
this concurrence, and since then it has been frequently seen, especially 
in consequence of the observations of Lancereaux in 1887. Hansemann 
states that during ten years there were examined at the Berlin Patho- 
logical Institute forty cases of diabetes in which pancreatic disease was 
present, nineteen cases of pancreatic disease without diabetes, and eight 
cases of diabetes without pancreatic disease. Proof of the etiological 
importance of pancreatic disease in the production of diabetes was fur- 
nished by the experiments of Yon Mering and Minkowski in 1889. 
They showed that the complete removal of the pancreas in dogs was fol- 
lowed within twenty-four hours by the characteristic symptoms of severe 
diabetes, ending fatally in a few weeks. This result did not follow liga- 
ture of the duct. If a very small portion of the pancreas was left in 
the animal, mild diabetes occurred. Sandmeyer observed that when 
about four-fifths of the pancreas were removed a mild diabetes resulted, 
which later became severe and ended in the death of the animal. These 
experiments suggest that it is a function of the pancreas to control the 
metamorphosis of sugar in the body, and that when this function is de- 
stroyed the sugar is eliminated by the kidneys. There is no satisfactory 
explanation of this result, although Lepine suggests that the pancreas pro- 
duces a ferment which is necessary to the normal metamorphosis of sugar. 

Morbid Anatomy. — In many cases of diabetes no lesions are to be 
found. In others the alterations observed are to be regarded as complica- 
tions of the disease, while in a certain number of cases lesions of the 
pancreas and tissues in its vicinity are present. Although glycosuria 
has been repeatedly observed in the presence of lesions, especially tumors 
and hemorrhage in the vicinity of the calamus scriptorius in the fourth 
ventricle, it is questioned whether the accompanying glycosuria should 
be regarded as necessarily indicative of diabetes. The lesions of the 
pancreas which have been found in diabetes are various. They consist of 
atrophy, fatty degeneration, suppurative and fibrous inflammation, con- 
cretions, cysts, and tumors. The liver is often hypertrophied, in part from 
the enlargement of the cells, in part from the presence of an increased 
quantity of blood. The periphery of the lobules frequently gives a red- 
dish-brown color when tincture of iodine is applied, in consequence of the 
presence of glycogen. The kidneys are often enlarged and injected, and 
the presence of glycogen may be recognized by the application of iodine 
to the tubes of Henle near the bases of the Malpighian pyramids. At 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



87 



times fatty degeneration of the tnbular epithelium is present. Numerous 
instances have been reported of fat-drops in the blood and of fat-emboli 
in the lungs, especially after death from coma. Glycogen has been found 
in the polynuclear leukocytes. The lungs are frequently diseased in 
diabetes, evidences of tuberculosis being often observed. The appearances 
of acute fibrinous pneumonia are frequently present, and gangrene of the 
lung is not a rare occurrence. 

Symptoms. — The onset of diabetes is usually gradual, the symptom 
first attracting attention being an increase in the quantity of urine. 
Various manifestations of disturbance of digestion or of the nervous sys- 
tem may precede polyuria, and are likely to follow this symptom. The 
abundant flow of urine is associated with a frequent desire to pass water, 
an abnormally large quantity being evacuated at each effort. The quan- 
tity secreted in the twenty- four hours may vary from three quarts to sev- 
eral gallons. It is diminished during intercurrent febrile affections, and 
a sudden diminution in quantity may immediately precede an attack 
of coma. Exceptionally there may be no increase in the flow of urine. 
Next in importance to polyuria as an early symptom is excessive thirst, 
often compelling the patient to have a pitcher of water at the bedside, 
from which frequent draughts are made during the night. The intensity 
of the thirst is in direct proportion to the frequency of micturition and 
the quantity of urine passed. This craving for water is a nervous symp- 
tom, and may be regarded as an attempt of the organism to eliminate 
the excess of sugar present in the blood. The appetite is usually exces- 
sive, and, despite large quantities of food, the sensation of hunger per- 
sists. Polyuria, polydipsia, polyphagia, and glycosuria continue through- 
out the disease, and are associated with various disturbances of nutrition. 
The patient loses flesh and strength. The skin becomes dry, and is fre- 
quently the seat of pruritus, especially near the anus and the genitals. 
Eczema, boils, and carbuncles often occur. In the later stages of dia- 
betes gangrene of the skin is frequent. Hanot and Chauflard in 1892 
reported the occurrence of cutaneous pigmentation, and since then, ac- 
cording to Mosse and Daunic, eight cases have been reported. A pig- 
mented fibrous liver is associated. The gums swell and bleed easily, and 
the teeth become carious, the presence of sugar favoring bacterial growth 
and its destructive influence upon the teeth. The odor of the breath is 
often fruity. Cataract occasionally occurs, usually in the later stages of 
the disease. During the loss of flesh and*strength various disturbances 
of the nervous system arise. The patients are depressed, suffer from 
headache and sleeplessness, and are especially prone to attacks of neu- 
ritis, resulting in pain and other disturbances of sensibility. Localized 
muscular paresis and absent patellar reflexes are relatively frequent. 
Disturbances of vision may be connected with retinitis or muscular pare- 
sis. The loss of sexual power in male patients often occurs, and may be 
an early symptom. 



88 



GENERAL DISEASES. 



Diabetes is unaccompanied by fever. There is no disturbance of cir- 
culation, except a weakening of the pulse in the later stages of the dis- 
ease. The respiration is usually undisturbed, except in diabetic coma 
or in complicating pulmonary affections or in asthma. The lungs are 
frequently the seat of tubercular processes, and become readily infected 
by pneumococci ; hence chronic pulmonary tuberculosis and acute pneu- 
monia are complications of relative frequency. A complication of occa- 
sional occurrence, especially late in the disease, is nephritis characterized 
by albuminuria and dropsy. Cystitis is occasionally met with, and gas, 
presumably carbonic acid, has been observed to have formed in the 
bladder, attributed to fermentation of the sugar in the urine from the 
presence of fungi. The urine is acid, its specific gravity froni 1025 to 
1050 and upward, although when diabetes is complicated with a fibrous 
nephritis the specific gravity may be below 1020. It is clear, of a pale 
yellow color ; the odor at times is fruity, and has been compared to that 
of new-mown hay. This peculiar odor is due to the presence of acetone, 
which is sometimes accompanied by diacetic acid, the urine then be- 
coming of a reddish-brown color on the addition of a few drops of dilute 
ferric chloride solution. The presence of these constituents as well as 
that of /5-oxybutyric acid, according to Weintraud, is due to the disturbed 
oxidation of the albuminous substances in the food and in the body. The 
high specific gravity is owing to sugar, of which ten per cent, or more 
may be present. The tests for glucose are given under Examination of the 
Urine. The quantity of sugar eliminated is generally in proportion to the 
quantity of urine passed, and may vary in twenty- four hours from several 
ounces to two pounds. It is usually increased when the food contains 
abundant starches and sugar, and diminished when such articles of food 
are excluded from the diet, when excessive muscular exercise is taken, or 
when intercurrent attacks of fever occur. The elimination of urea and of 
the phosphates is markedly increased. In a case reported by Kobert fat 
was periodically passed in the urine. Traces of albumin are frequent, 
even in the absence of nephritis. The faeces are usually less abundant 
than in health, and in rare instances contain either liquid or solid fat. 

Diabetes is conveniently divided into the mild and severe varieties, 
although this distinction is not absolute, since mild cases may become 
severe. The mild form may exist for years in apparently healthy, often 
well-nourished individuals, the glycosuria being accidentally discovered. 
The morning urine may be fre'e from sugar, while that voided a few hours 
after a meal of carbo-hydrates shows its presence. Severe diabetes is 
oftener found in the young, or in those mild diabetics who from inability, 
ignorance, or negligence have not lived upon an antidiabetic diet. Ema- 
ciation is conspicuous, the grave symptoms above mentioned are present, 
and the patient is likely to live but a few years. In mild diabetes, when 
carbo-hydrates are taken, there is usually less than one per cent, of sugar 
in the urine, and this disappears in the course of a few days when an 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



89 



antidiabetic diet is adhered to. The longer the time necessary to produce 
the disappearance of the sugar the more closely allied is the case to the 
severer type. In severe diabetes the percentage of sugar is higher, and 
glycosuria persists despite the use of a diet largely restricted to albumi- 
nates. Naunyn has observed in certain cases that more sugar is excreted 
with a diet of abundant meat than when but little meat is taken. 

The term diabetic coma was first used by Kussmaul to include a series 
of severe symptoms ending in coma which immediately precede death in 
certain cases of severe diabetes. The coma might occur suddenly and 
unexpectedly, or be preceded by increasing debility, excessive mental or 
physical exertion, digestive disturbances, and inflammatory affections, 
especially pneumonia. A brief period of headache, restlessness, wake- 
fulness, or excitement precedes the drowsiness, sopor, and coma, which 
are in rapid sequence. Diabetic dyspnoea is often associated, and is 
characterized by frequent, deep, and somewhat noisy respiration, perhaps 
accompanied with a dusky skin. The breath presents the odor of acetone. 
The ferric chloride test indicates the presence of diacetic acid in the urine, 
and Kulz and others state that peculiar casts are frequently to be found in 
the urine before and during the attack of coma. According to Yon 
Mering, abundant oxybutyric acid or ammonia in the urine is indicative 
of a threatened coma. The cause of diabetic coma is unknown, although 
probably in considerable part an auto-intoxication from a variety of 
chemical substances, while in certain cases fat-embolism may be of im- 
portance, especially in the production of dyspnoea, as suggested by San- 
ders and Hamilton. The coma lasts a few hours or a few days, and 
generally ends in death. 

Diagnosis. — A suspicion of diabetes should arise when the patient 
complains of polyuria, and even in a young child, if there is incontinence 
of urine, diabetes is to be considered as the possible cause. The diag- 
nosis consists in the determination of the persistent, not the transitory, 
presence of sugar in the urine. For this purpose the examination of the 
urine voided several hours after a meal containing carbo-hydrates has 
been taken should be made in doubtful cases, and cases of intermitting 
diabetes are to be borne in mind in which periodical examinations of the 
urine may be necessary owing to the temporary absence of sugar from the 
urine even after farinaceous food. The routine examination of the urine 
for sugar will often explain the origin of mental or physical debility, per- 
sistent neuralgia, and genital or anal pruritus without apparent cause. 
It is also to be remembered that designing persons, the hysterical for in- 
stance, may add sugar to the urine after it is passed. When in any case 
of diabetes there is a large excretion of sugar without a corresponding 
polyuria, the existence of organic disease at the base of the brain should 
be suspected. 

Prognosis. — Diabetes mellitus is essentially an incurable disease, 
although under appropriate treatment the milder cases may live through- 



90 



GENERAL DISEASES. 



out a period of many years. In severe diabetes death usually takes place 
in from one to three years. Even in mild cases the prognosis must be 
guarded, from the difficulty of adhering to a restricted diet and the in- 
ability to avoid mental and physical strain or excess. The younger the 
patient the worse the prognosis. Fat diabetics usually suffer less and 
live longer than the lean. The course of a mild diabetes may suddenly 
or rapidly become serious from an intercurrent pneumonia or a com- 
plicating tuberculosis. The odor of acetone in the breath, the ferric 
chloride reaction in the urine, and the unexpected appearance of casts 
are bad prognostic signs, the successive occurrence of each being of the 
gravest import. 

Treatment. — Diabetes due to some gross lesion encroaching upon 
the medulla oblongata is to be relieved by curing the original disease or 
not at all. Thus, we have seen antispecific treatment by curing a cerebral 
syphilis cure the diabetes which was its chief symptom. 

In gouty diabetes the basal treatment should be that of gout. The 
diabetes may yield entirely, but is very apt to recur, and finally to require 
diabetic treatment. 

In idiopathic or true diabetes the chief reliance of the therapeutist 
must be upon the removal of the vegetable carbo-hydrates from the 
food ; neither sugar, starch, nor food containing them is to be allowed. 
Saccharin may be employed as a harmless substitute for sugar, but un- 
fortunately it is almost impossible to still the natural craving for starchy 
food. The so-called gluten and washed bran always contain starch, and 
the ordinary commercial gluten contains a large quantity of starch ; 
nevertheless, bread made of these substances is much less harmful than 
that made out of flour from which no attempt to remove the starch has 
been made ; it is, however, less satisfying, and in some cases it is better 
to allow a crust of bread to be taken. As further substitutes for bread, 
cakes of an almond flour from which the sugar has been removed, and 
also bread or cakes of inulin, may be used. The following diet-list, based 
upon that made by Austin Flint, indicates the allowable articles of food : 

Breakfast. — Oysters or clams stewed, without flour ; beefsteak, beef- 
steak with fried onions, broiled chicken, mutton-chops or lamb-chops, 
kidneys broiled, stewed, or devilled ; tripe, pigs' feet, game, ham, bacon, 
devilled turkey or chicken, sausage, corned beef hash without potato, 
minced beef, turkey, chicken, or game ; all kinds of fish, fish-roe, fish- 
balls without potato ; eggs cooked in any way except with flour or 
sugar, scrambled eggs with chipped smoked beef, picked salt codfish 
with eggs ; omelets plain or with ham, with smoked beef, or with 
kidneys ; asparagus- points, fine herbs, parsley, truffles or mushrooms, 
radishes, cucumbers, water-cress ; butter, pot-cheese ; tea or coffee with 
a little cream but no sugar (glycerin or saccharin may be used instead 
of sugar if desired) ; light red wine for those who are in the habit of 
taking wine at breakfast. 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



91 



Lunch or Tea. — Oysters or clams cooked in any way except with 
flour ; chicken, lobster, or any kind of salad except potato ; fish of all 
kinds ; chops, steaks, ham, tongue, eggs, crabs, or any kind of meat ; 
head- cheese $ red wine, dry sherry, or Bass's ale. 

Dinner. — Eaw oysters or clams. 

Soups. — Consomme of beef, of veal, of chicken, or of turtle ; con- 
somme with asparagus-points ; okra, ox-tail, turtle, oyster, or clam, 
without flour ; chowder without potatoes ; mock-turtle, mullagatawny, 
tomato, gumbo fillet. 

Fish. — All kinds of fish, lobsters, oysters, clams, terrapin, shrimps, 
crawfish, hard-shell crabs, soft-shell crabs. (No sauces containing flour.) 

Eelishes. — Pickles, radishes, celery, sardines, anchovies, olives. 

Meats. — All kinds of meat cooked in any way except with flour 5 all 
kinds of poultry without dressings containing bread or flour; calf's head ; 
kidneys, sweetbreads, lamb-fries, ham, tongue : all kinds of game ; veal, 
fowl, sweetbreads, etc., with curry, but not thickened with flour. (No 
liver. ) 

Vegetables. — Truffles, lettuce, chiccory, endive, cucumbers, spinach, 
sorrel, beet-tops, cauliflower, cabbage, Brussels sprouts, dandelions, to- 
matoes, radishes, oyster-plant, celery, onions, string beans, water-cress, 
asparagus, artichoke, parsley, mushrooms, and all kinds of herbs. 

Sweets. — Brandied peaches and other fruits j omelets and calf 's-foot 
jelly, sweetened, if desired, with saccharin. 

Miscellaneous. — Butter, cheese of all kinds, eggs cooked in all ways 
except with flour or sugar, sauces without sugar or flour, almonds, hazel- 
nuts, walnuts, cocoanuts, tea or coffee with a little cream but without 
sugar. 

In bad cases of diabetes the absolute skim- milk, buttermilk, or 
koumiss diet, which has been strongly recommended by Donkin and 
by Tyson, may be tried : it is asserted that milk-sugar, as well as man- 
nite and levulose or fruit-sugar, is incapable of conversion in the system 
into true sugar. When, however, milk or any substance containing 
levulose is given, the effect of the food upon the sugar elimination should 
be carefully watched. 

The diabetic patient should always be warmly dressed, should be very 
carefully protected against exposure, and should sedulously avoid ex- 
cessive mental or physical labor ; whilst by means of frequent bathing 
the skin should be kept thoroughly active. Certain mineral springs, 
especially Vichy and Carlsbad, are much resorted to by diabetics, but are 
probably chiefly of service in the gouty forms of the disease and where 
there is evidently habitual engorgement of the liver and other viscera. 
Very often, however, alkaline waters are useful as adjuvants. 

Strychnine, laxatives, cod-liver oil, and other remedies may be useful 
to meet symptoms as they arise. Arsenic, especially the arsenite of 
bromine (one-sixteenth of a grain a day increased to one-sixth of a grain 



92 



GENERAL DISEASES. 



in ascending doses), antipyrin (especially in neurotic cases), potassium 
bromide, and numerous other remedies have been in vogue, but rarely 
exert a distinct influence for good. Jambul has undoubtedly the power 
to check the action of diastase upon starch, and has been used in India 
in diabetes almost from time immemorial : we have seen the sugar disap- 
pear from the urine under its administration, but think it will generally 
be found to fail. The fluid extract should be used in a commencing dose 
of ten minims in capsule, three times a day, increased to forty or fifty 
minims. Extract of ergot has been largely used and lauded ; if given at 
all it should be in full dose, one or two drachms a day in capsule. Opium 
seems to be the only remedy which is capable of distinctly checking the 
progress of the disease in most cases. It may be used in the form of the 
extract, or of morphine, or of codeine. The codeine is, we believe, the 
least successful of the opiate preparations ; as, however, it produces much 
less disturbance of the general system than does the opium, it may be 
tried first ; half a grain should be given three times a day and rapidly in- 
creased until thirty to forty grains a day are taken. Opium is better than 
morphine, and the extract is preferable to the opium itself ; one-quarter 
of a grain of the extract should be given three times a day at first and 
slowly increased until ten or even more grains are taken daily. At no 
time should sufficient of the opium be given to produce narcosis. Prepa- 
rations of pancreas have been used, in accordance with the pancreatic 
theory of the disease, but have not been sufficiently tested to warrant 
any definite conclusion ; thus far the success does not seem to have been 
brilliant. The glycolytic ferment isolated by Lepine from the pancreas 
and from malt diastase is also worthy of further trial. 

Diabetic coma is almost hopeless. Intravenous or subcutaneous in- 
jections of a three per cent, solution of sodium bicarbonate have been 
practised, but their use seems warranted only by the therapeutic despair 
which surrounds the case. 

DIABETES INSIPIDUS. 

Definition.— A chronic disease characterized by the excretion of a 
large quantity of urine which contains no sugar. 

Etiology. — Diabetes insipidus is a disease more often found in males 
than in females ; it is more frequent in the first half of life, and may occur 
even in young children. Heredity at times seems to be of importance in 
the etiology. Claude Bernard found that injury to the floor of the fourth 
ventricle near the seat of the sugar-puncture, and also section of the 
splanchnic nerves, produced temporary polyuria. Peyrani has caused 
polyuria by irritation of the cervical sympathetic, and Kahler has induced 
permanent polyuria in rabbits by injury to the cerebellum and medulla 
oblongata. The importance of affections of the nervous system in the 
etiology of diabetes insipidus is further shown by the occurrence of this 
affection after injury to the cranium, sunstroke, inflammation of the 



LOCOMOTOR AND CONSTITUTIONAL DISEASES. 



93 



brain and its membranes, cerebral tumors and syphilis, myelitis, and 
fright. Kahler observed that these affections of the brain when focal 
were more frequently seated in the posterior cranial fossa. Diabetes 
insipidus has also developed in acute infectious diseases, in scurvy, in 
saccharine diabetes after the disappearance of the sugar, and as a result 
of excessive drinking. It has been noted in connection with abdominal 
tumors, especially when in the vicinity of the coeliac plexus, and as an 
accompaniment of chronic inflammatory processes in the same region. 

Morbid Anatomy. — The above-mentioned lesions of the nervous 
system and of the abdomen should be sought for, and, if found, as sug- 
gested by the results of experiments, offer a probable explanation of the 
disease. The kidneys are large, and in certain cases the pelves and 
ureters are dilated and the bladder is hypertrophied. 

Symptoms.— Polyuria is the characteristic symptom. It may be of 
rapid origin or may gradually and progressively develop. The daily 
quantity of urine excreted may be from one to two gallons and upward. 
The urine is pale and colorless, acid, the specific gravity usually below 
1005. It is free from albumin, and contains no sediment. Inosite has 
sometimes been found, and the temporary occurrence of glucose has been 
observed. The absolute quantity of the solid constituents of the urine is 
generally unaltered. In certain cases or at certain times an increase of 
urea has been found, a condition to which the term azoturia has been 
applied. 

Excessive thirst, polydipsia, is the usual accompaniment of the poly- 
uria. In the mild cases there may be no further disturbance. The pres- 
ence of headache, vertigo, mental excitability or depression, and neuralgia 
indicates a transition to the severer type, which is further manifested by 
hebetude, loss of flesh and strength, dryness of the skin, and weakness 
of the pulse. 

Diagnosis. — The diagnosis is based upon the occurrence of polyuria 
and the examination of the urine. Hysterical polyuria is spasmodic and 
not persistent, and therefore to be differentiated. The polyuria of chronic 
fibrous nephritis is to be excluded by the absence of albumin and casts, 
and the freedom from evidence of hypertrophy of the heart. In hydro- 
nephrosis, especially the intermittent variety, large quantities of urine 
may be occasionally voided. This affection, however, is to be excluded 
by the absence of a tumor diminishing in size with the abundant flow 
of urine ; the latter is either of relatively normal composition or presents 
the characteristics of the urine of fibrous nephritis. 

Prognosis. — In some cases diabetes insipidus continues for years, 
perhaps throughout life, without serious disturbance. Death in fatal 
cases is rather attributable to the cause or to complications than to 
the disease directly. Eecovery is rare unless the exciting cause — e.g., 
syphilis — is remediable, although temporary improvement may take 
place. 



94 



GENERAL DISEASES. 



Treatment. — In the treatment of diabetes insipidus it is essential to 
obtain the best hygienic surroundings for the patient, to forbid excessive 
mental or physical work, and in every way possible to maintain the gen- 
eral health. The diet should be nutritious, but not special ; the clothing 
should be warm, so as to keep the skin protected and active, and the 
thirst should not be fully satisfied. Extract of ergot (ten grains in cap- 
sule, three to six times a day), valerian (one-half to one fluidounce daily), 
and zinc valerianate (one to two grains in capsule, three to four times a 
day), are the most effective remedies, although the salicylates, arsenic, 
antipyrin and other coal-tar products, the bromides, belladonna, strych- 
nine, and numerous other remedies, have been from time to time com- 
mended. 

In giving any of these remedies the dose should be increased until 
some therapeutic or physiological effect is produced. 



INFECTIOUS DISEASES. 



95 



CHAPTER III. 

INFECTIOUS DISEASES. 
SCARLATINA. SCARLET FEVER. 

Definition. — A contagious febrile disease, characterized by a pecu- 
liar diffused eruption and a pronounced tendency to the development of 
serious sore throat. 

Etiology. —Scarlet fever is probably always the result of a contagion, 
which may pass directly by contact with the person of the sick or be 
transmitted through the air, or be carried by fomites. The power of the 
poison to resist change is very great, as is also its ability to pass into milk 
and other articles of food, and to adhere to letters and other media of 
transmission. Various investigators during late decades have attempted 
to connect certain diseases of cows and of other lower animals with scarlet 
fever of man, but as yet there is no sufficient reason for believing that 
scarlet fever can be transmitted from man to the lower animals, although 
cats may act as carriers of the poison. 

Although various pathogenic germs have been isolated from patients 
suffering from scarlet fever, the true nature of the contagion remains un- 
known. Streptococci, diplocoeci, micrococci, bacilli, and other organisms 
have, it is true, been found, but all appear to be the result of secondary 
infection. It is important to note that the diphtherial organism can often 
be obtained in abundance from the pseudo-membranous angina of scarlet 
fever ; but, on the other hand, the most violent sore throat with abundant 
exudate may exist without the diphtheritic bacillus. 

Morbid Anatomy. — The anatomical changes in fatal cases of scarlet 
fever are most frequent in the throat and kidneys. The mucous mem- 
branes of the pharynx, soft palate, and tonsils are swollen, injected, per- 
haps hemorrhagic. There may be an adherent false membrane due to 
the presence of bacteria, sometimes of the diphtheria bacillus. Super- 
ficial ulceration and deep necrosis of the tissues are not infrequent. In 
some instances the neighboring lymphatic glands are swollen and in- 
jected and may contain abscesses, while the surrounding fibrous tissue 
is cedematous. 

The kidneys are likely to show the characteristics of an acute ne- 
phritis in a mild or a severe form. The kidney is usually enlarged, the 
region of the convoluted tubes abnormally opaque. It may be injected, 
sometimes containing hemorrhagic spots beneath the capsule and on 
section, or it may be abnormally pale. The alterations of the kidney es- 
pecially characteristic of scarlet fever are those which were first described 
by Klebs and Friedliinder and designated as a glomerulo-nephritis. The 



96 



GENERAL DISEASES. 



changes consist in enlargement of the glomeruli and a thickening of 
the capillary wall, an increase of the nuclei, and a swelling and necrosis 
of the capsular epithelium. Collections of leukocytes in the interstitial 
tissue are to be found in various parts of the kidney. The diseased 
Malpighian bodies appear to the naked eye as pale gray translucent 
points. 

Granular degeneration of the heart and liver and moderate acute 
enlargement of the spleen are present. The rash leaves no gross evi- 
dence of its presence in the skin except in hemorrhagic cases, when 
punctate hemorrhage is to be found. Hemorrhage may also take place 
in the mucous membrane of the intestine. Pseudo- membranous patches 
are sometimes to be found in the stomach and intestine. The lymphatic 
glands of the body may be enlarged, and Wagner has described the 
presence of a disseminated formation of lymphadenoid tissue in the 
liver and kidneys. 

Symptomatology. — The ordinary period of incubation of scarlet 
fever is from three to five days, though well authenticated and carefully 
studied cases have been reported by Trousseau and others in which it was 
twenty-four hours, whilst it may be prolonged to ten or even twelve days. 
The invasion of the disease is usually abrupt ; in the mildest cases it is 
marked by nausea and chilliness, in the ordinary cases by one or more 
chills, and by vomiting, which is apt to be repeated and severe. The 
pulse becomes at once rapid and small (120 to 150), and the axillary 
temperature rises to 103°, or it may be 105° or 106° F. There is great 
dryness of the skin, mouth, and throat, whilst the tongue is covered with 
grayish fur, and the fauces are distinctly red. Conjunctival, nasal, or 
bronchial catarrh is very exceptional. In from twelve to thirty-six hours 
the characteristic eruption appears, in most cases first upon the upper 
chest and the back, but sometimes upon the extremities, and in excep- 
tional cases upon the cheeks. The spreading of the eruption is so rapid 
that usually in twelve hours it covers the whole body. It consists of a 
scarlet or deep -red punctated or stippled efflorescence ; sometimes it is 
minutely papular. Under pressure with the finger the color disappears, 
but reappears immediately upon removal of the pressure. Ordinarily the 
rash is nearly uniform, but it may be in patches. It is especially dark 
colored in the groin and in the folds of the skin made by flexion of the 
extremities. On the nose, lips, and chin it is often wanting, whilst it is 
always very pronounced upon the cheeks. When it is fully developed it 
is sometimes accompanied by an eruption of miliary vesicles, although 
the skin is very dry and pungent. The eruption also attacks the mucous 
membranes, so that the cheeks and the throat are brilliant red, swollen, 
and often distinctly punctated. The tongue, though red on the tip and 
edges, is covered with a whitish fur from which project the red papillae 
(strawberry tongue). A few days later desquamation leaves the surface 
of the tongue red and rough, with greatly enlarged, very dark red papillae 



INFECTIOUS DISEASES. 



97 



(raspberry tongue) 5 a condition which may last as long as five days. 
At this stage the tonsils are swollen, with their crypts distended with a 
yellowish- white creamy exudate, which often spreads over the surface 
to make a sort of false membrane. The contention of Lasegue, that 
there is a vesicular eruption upon the mucous membrane at this time, is 
plausible. The submaxillary glands and the surrounding cellular tissues 
are always swollen. 

The coming out of the eruption is not followed by any immediate 
remission of the general symptoms 5 the fever remains high, the pulse 
rapid, headache is often extreme, and there is very commonly a nervous 
agitation which may rise to distinct delirium. There are extreme thirst, 
complete anorexia, more or less constipation ; but vomiting is rare after 
the second day. The urine is, throughout the attack, of high specific 
gravity, dark- colored, and very commonly contains a trace of albumin as 
early as the second day of the disease. In favorable cases there may be a 
gradual abatement of the symptoms after the second or third day of the 
eruption ; often, however, the constitutional disturbances do not subside 
until the sixth or seventh day, when desquamation has fully begun. 

The characteristic course of the fever in scarlet fever is a sudden rise 
of temperature, with a maximum reached in the first twenty-four or forty- 
eight hours, followed by a continuous fever, with mild morning remis- 
sions and a general tendency to decrease slowly during the next five or 
six days, at the end of which time there is a rapid but not abrupt defer- 
vescence. Sometimes the temperature drops and the rash fades on the 
second or third day, both to reappear in a day or two. The quickening 
of the pulse and that of the respiration in most cases correspond to the 
rise of temperature, upon which they probably are largely dependent. 

Although the protective power of an attack of scarlet fever cannot be 
gainsaid, it is certain that, especially in susceptible individuals, there 
may be repeated attacks, which may consist simply of a bad sore throat 
with some febrile reaction. Between such attacks (the mildest possible) 
and those in which the patient passes immediately into collapse and dies 
in a few hours overwhelmed by the poison, there is every grade or variety 
of scarlatina ; but, in obedience to custom, three types may be recognized, 
— the simple, the anginose, and the malignant. 

The simple scarlet fever is that which has already been described in 
the text. In the anginose scarlet fever the throat symptoms appear very 
early, and are attended with great swelling, and with the rapid formation 
of a membranous exudate which may extend upward into the nostrils, 
forward into the mouth, and downward into the pharynx and larynx. 
The excessive" fetor, the rapid swelling of the glands of the neck, and 
the tendency to necrosis of the mucous membrane may make a picture 
indistinguishable from that of malignant diphtheria, and death may 
result from a septicaemia produced by the local disease of the throat, or 
the ulcers may open the carotids or other blood-vessels and cause fatal 

7 



98 



GENERAL DISEASES. 



hemorrhage. Inflammations of the Eustachian tube and of the middle 
ear are common phenomena. 

In malignant scarlet fever violent headache, vomiting, dyspnoea, cya- 
nosis, convulsions, delirium, coma, and intense fever may end in the 
course of a few hours, without eruption, in death ; or the attack may at 
first seem not overwhelming, but be followed in a few hours by violent 
adynamia, with great heart- failure, weakness of the extremities, exces- 
sive dyspnoea, and nervous disturbance j sometimes the malignant symp- 
toms first develop after the appearance of the eruption, which may be 
intense and wide- spread. In most cases of malignant scarlet fever vomit- 
ing is pronounced, and not rarely there is diarrhoea. A sudden rise of 
temperature immediately preceding death is also frequent, even at a time 
when the extremities are very cold and the patient in collapse. In the 
hemorrhagic malignant scarlet fever epistaxis and abundant hsematuria 
may precede or follow the occurrence of the purpuric and petechial erup- 
tion, and death may take place almost immediately in collapse, or be pre- 
ceded by intense fever, violent dyspnoea, convulsions, and delirium. A 
rare form of malignant scarlet fever is that in which all the symptoms 
are lost in a furious choleraic diarrhoea. 

Eelapses in scarlet fever are rare, but do occur, with the reappear- 
ance of the fever, the sore throat, and the eruption. The time of their 
reappearance is from twelve to thirty-six days after the first attack. 

Complications. — The complications of scarlet fever are often very 
serious. True diphtheria may develop, or there may be a wide-spread 
gangrene of the throat without diphtheria. Severe adenopathies are very 
common, especially in the submaxillary and sterno- mastoid region, and 
may end in suppuration during the height of the attack, or more fre- 
quently during the early days of convalescence, with a resultant severe 
or even fatal septicaemia. In some cases of scarlatina the enlarged lym- 
phatic glands harden into a brawny mass, exceedingly intractable to all 
medical treatment. Middle- ear inflammation occurs probably in about 
thirty per cent, of the cases, and according to Burckhart-Merian a severe 
suppurative otitis media develops in about four and a half per cent., 
usually during the period of eruption, revealing itself by violent earache, 
insomnia, and excessive tenderness of the mastoid processes. 

Among the complications or sequelae of scarlet fever should be men- 
tioned multiple abscesses, pyothorax, suppurative pericarditis, endocar- 
ditis, and certain arthropathies which have been incorrectly considered 
as rheumatic. Of scarlatinal rheumatism, so called, there are three forms : 
that in which the exudate is serous, that in which it is primarily serous 
and secondarily purulent, and that in which pus is formed from the begin- 
ning. The affection generally begins from the fifth to the seventh day 
of the fever, or rarely during the stage of desquamation. It sometimes 
attacks many joints, but is usually localized in a single articulation. 
Recovery in the course of a few days is common with the serous exudate j 



INFECTIOUS DISEASES. 



99 



recovery with more or less permanent change in the joint is the rule 
when the exudate is first serous and then purulent ; but when from the 
beginning pus forms in the joints, death from pyaemia is the common 
result. It is probable that these complications are due to streptococcus 
poison from the throat. 

The nervous sequelae of scarlet fever are usually not severe, but chorea, 
hemiplegia, mania, and melancholia have all been reported, and prob- 
ably multiple neuritis is more frequent than is generally believed. 

Of all the complications of the disease nephritis is the most impor- 
tant. Not rarely, even in mild scarlet fever, when the temperature rises 
very high, albumin and even casts appear in the urine during the first 
twenty-four hours : they are the result of the hyperthermia, and have 
no greater significance than in various other febrile diseases, passing 
off without serious result. The characteristic nephritis of the disease 
develops most frequently in the second or third week, but may be delayed 
to the fourth or even sixth week. It may follow the mildest form of the 
disease, and come on when all the symptoms seem most favorable. The 
first evidence is usually an anasarca just below the eyes, which often is 
first detected in the early morning. The nephritis varies greatly in in- 
tensity ; in the severest cases there are aching pains in the back, chills, 
vomiting, hseinaturia, and a partial or even finally complete suppression 
of the urine, with ursemic symptoms after some hours. Furthest removed 
from these cases are those in which the symptoms are so mild that they 
can scarcely be noted, — a little albuminuria, a few casts, some oedema. 
Between the two extremes may be found every variety of severity. 
Among the subacute cases are many in which without great care the 
symptoms, at first so slight as to be easily overlooked, progress to great 
seriousness, with profound alteration of the kidney. As oedema about 
the eyes may occur without the appearance of albumin in the urine, its 
presence is not a proof of nephritis. Again, there is much reason for 
believing that a dangerous nephritis may exist and yet the urine be tem- 
porarily free from albumin, so that repeated examinations are necessary 
for the detection of the kidney disease. (Edema of the lungs and acute 
oedema of the glottis are more frequent in severe than in mild cases of 
scarlatinal nephritis, but may suddenly appear in any case. 

Diagnosis. — The diagnosis of scarlet fever in the stage of incubation 
depends upon the severity of the symptoms, the presence of vomiting, 
and the rapid rise of temperature. In malignant cases without the de- 
velopment of the rash the diagnosis must be made by exclusion, aided by 
the history of exposure to cause. The rashes produced by antipyrin, 
belladonna, oil of copaiba, and some other drugs resemble somewhat 
the rash of scarlet fever, but the absence of fever and of sore throat, with 
the presence of other symptoms of poisoning, usually makes the diag- 
nosis easy. Acute exfoliative dermatitis may develop without obvious 
cause, and, as it has a sudden onset, a brilliant exanthem closely resem- 



100 



GENERAL DISEASES. 



bling that of scarlet fever, and distinct fever with nervous phenomena, 
it may at first be impossible to distinguish it from scarlatina. The ab- 
sence of throat symptoms and of the peculiarities of the tongue of scarlet 
fever, and the fact that the desquamation affects the hair and the nails, 
usually make the final recognition easy. 

The diagnosis between diphtheria and scarlet fever is not always 
possible ; because undoubtedly diphtheria is sometimes accompanied by a 
scarlatinal rash, whilst Loeffler's bacillus may be present in scarlet fever. 
In other words, a pure diphtheria may closely simulate a scarlet fever, 
and diphtheria frequently coexists with a scarlet fever, so that at times 
the most acute practitioner cannot unravel a case sufficiently to know 
whether he has one simply of diphtheria or one of mixed infection. 
In some cases a history of exposure may greatly aid in the diagnosis. 
Fortunately, so far as treatment is concerned, the diagnosis is of little 
practical importance, as the treatment of the scarlet fever complicated 
with diphtheria would be precisely that of a diphtheria simulating scarlet 
fever. 

Prognosis. — The mortality in scarlet fever varies in different epi- 
demics and under different circumstances from one to forty per cent. 
It is greater in hospital practice than in civil life, among the poor than 
among the rich. In children under one year the death-rate is very high, 
but it diminishes after the first year until it reaches its mi n imum between 
six and twelve years of age. Any previous disease or diathesis greatly 
increases the danger. The prognosis is grave in proportion to the severity 
of the early symptoms ; high fever, great adynamia, restlessness, intensity 
of the sore throat, any of these occurring early are very serious, as are 
also extreme rapidity of the pulse and elevation of the temperature. A 
precocious painful swelling of the submaxillary gland is of evil import. 
The majority of cases of nephritis recover under careful treatment, but a 
complete early suppression of urine is very dangerous. 

Treatment. — Absolute isolation in a fully ventilated room, with all 
the precautions as to bedclothing, etc., which are especially described in 
the article on typhoid fever, are essential in the treatment of scarlet fever. 
The activity of the contagion and the seriousness of the disease make it 
imperative that the physician should carefully supervise the disinfection 
of the sick-room. 

Although belladonna, mercurials, salicylic acid, and various other 
drugs have been recommended as specifics, there is no remedy which has 
any power to affect the course of the fever. The symptoms must be met 
as they arise. When the vomiting is severe, carbonic acid water, lime 
water and milk, and bismuth, will often be found effectual. If these 
fail, a quarter of a grain of cocaine, in solution, every one or two hours, 
may be tried for a few doses. For the relief of nervousness and insomnia 
the bromides, frional or sulphonal, and chloral, used very carefully, are 
of value. Hyoscine will frequently control the delirium and produce 



INFECTIOUS DISEASES. 



101 



sleep, but is an extremely dangerous remedy, as by increasing the dry- 
ness of the throat and probably also by producing paralytic weakness 
of the throat it tends greatly to increase symptoms of suffocation in 
anginose cases : we have seen it apparently cause death in this way. 
In order to maintain the secretions, and especially to lessen the strain 
upon the kidneys, the child should be encouraged to drink cold, simple, 
or carbonated water very freely. 

Antipyretic treatment is in most cases essential. Phenacetin, anti- 
pyrin, and antifebrin will reduce the temperature, but certainly grave 
danger accompanies the free use of any of these remedies j although, on 
the other hand, small doses given at regular intervals may do great good 
by quieting the nervous disturbance and helping in the reduction of tem- 
perature. Quinine has been strongly recommended as an antipyretic by 
practitioners, but to have a distinct effect must be given in large doses, 
— a practice which, in our opinion, is not justifiable. On the other 
hand, when given in moderate dose it probably is of service in tending to 
reduce temperature, as well as by supporting the nerve-centres. The 
bisulphate should always be employed, as more easy of absorption, and 
if it irritate the stomach it should be given by the rectum, not in sup- 
positories, but in slightly acidulated (tartaric acid) solution. 

As the fever of scarlatina does not last over a few days, a temperature 
of 102.5° F. does very little harm. When, however, it rises to 103° F. or 
above, cold should be used externally, first by sponging, and, if this fail, 
by packing or by bathing. The severity of the baths must be propor- 
tionate to the resistance of the fever ; probably in most cases the bath at 
a temperature of 85° F. gradually reduced to 80° or 75° F. is the best. 
Leiter's tubes applied to the head and to the abdomen, with iced water 
run through them, sometimes suffice. The cold pack, or the bath, or 
whatever means is employed, must be used until the desired effect is 
produced, and be repeated whenever the temperature rises to 103° F. 
If there be a tendency to relapse, alcoholic stimulants should be given 
freely just before the patient is put into the bath ; and hot- water bottles 
or bags may sometimes be advantageously applied to the extremities 
whilst the patient is in the bath. 

The treatment of adynamia in scarlet fever is similar to that of ex- 
haustion from other fevers. (See Typhoid Fever.) As, however, there 
is a special tendency to irritation of the stomach and of the kidneys, 
ammonium carbonate and other irritating drugs must be avoided. 

Through the whole course of the disease the throat must be very 
carefully treated. The local external use of ice by india-rubber bags 
fastened around the neck underneath the jaws is often advantageous, 
whilst small pieces of ice may be allowed constantly to melt in the 
mouth. Potassium chlorate has been very largely used in scarlet fever, 
and is sometimes of service as a local remedy to the throat ; except for its 
local action it is of no value whatever, and it has without doubt aided in 



102 



GENERAL DISEASES. 



numerous cases in causing death by irritating the kidneys and increasing 
the danger of nephritis. Tincture of ferric chloride, solution of silver 
nitrate, glycerite of tannin, and various other astringent solutions are 
employed by different practitioners as local applications. Spraying the 
throat out, however, with a peroxide of hydrogen solution has seemed 
to us the best of all local treatment. (See Diphtheria.) The official 
preparation may be used of the full strength, or diluted one-half. When 
there is a tendency to closing of the nostrils, the spray should be thrown 
into the nostrils, if possible, from behind ; if not, from the front. 

If suppuration of a gland occurs, a free incision should be at once 
made. In order to allay the burning and itching of the skin, cosmoline, 
cacao butter, cold cream, lard freed from salt by washing, olive oil, or 
other bland fat should be freely applied to the surface of the body 
morning and evening, after the first or second day of the eruption. 
When the eruption retrocedes or fails to develop, the hot mustard bath, 
or, if there be high temperature, the cold mustard bath, will often be 
of service. The treatment of nephritis is that of acute nephritis from 
other cause. (See Acute Desquamative Nephritis.) 

RUBEOLA. MEASLES. 

Definition. — A contagious eruptive fever, characterized by the early 
and severe development of catarrhal symptoms, and the appearance on 
the third or fourth day of a peculiar eruption, which may be vesicular, 
but is usually composed of very minute papules, arranged in irregular, 
more or less crescentic patches. 

Etiology. — The cause of measles is always a contagion, whose nature 
has not yet been fully established. In searching for the supposed germ 
of the disease bacteriologists have found in various parts of the body 
streptococci, micrococci, bacilli, and other micro-organisms, which are 
without doubt due to secondary infection. The same appears to be true 
of the diplococcus obtained by Cornil and Babes, which is probably 
identical with the well-known pneumococcus of pneumonia. In 1892 
Canon and Pfeiffer discovered an organism in the blood as well as in the 
catarrhal secretions of patients suffering from measles, which is believed 
by some to be the specific germ of the disease. This organism is remark- 
able for its variations in size and shape ; it exists both as a diplococcus 
and as a bacillus as long as the diameter of a red blood- corpuscle. 

Although measles is most frequent in children, yet adults unprotected 
by a previous attack readily take the disease on exposure to the conta- 
gion, and both sexes are equally affected. One attack of measles affords 
a very decided but not completely perfect protection. 

Morbid Anatomy. — In fatal cases of measles death is usually the 
result of complications, especially in the respiratory tract. These are 
present as foci of broncho-pneumonia or of lobular pneumonia, with 
more or less extensive patches of atelectasis from obstruction of the 



INFECTIOUS DISEASES. 



103 



bronchi by catarrhal secretion. A persistence of such inflammatory 
conditions in the lungs is not infrequent in virtue of their infection 
with tubercle bacilli, and death may eventually result from pulmonary 
tuberculosis. 

Symptomatology. — The period of incubation is about ten days, at 
the end of which time an abrupt rise of temperature, to 102° or 103° F. 
the first day, with or without chill, occurs, and the characteristic catar- 
rhal symptoms appear. The conjunctivae become red and watery, there 
is frequent sneezing, with excessive nasal secretion, and not rarely epis- 
taxis, laryngitis, tracheitis, and even a mild bronchitis, rapidly develop. 
Of these catarrhal symptoms those concerned with the eyes and the nose 
are most pronounced, but even at this time the least exposure is liable to 
produce severe bronchitis or pneumonia. The throat is sometimes a 
little sore, but never as it is in scarlet fever. In many cases during the 
stage of invasion the hard and soft palates and the throat itself are very 
red and covered with minute spots or points, which are sometimes spoken 
of as an eruption upon the mucous membrane. For the next three or 
four days there are headache, malaise, pronounced fever, anorexia, and 
not rarely vomiting or diarrhoea. Severe nervous symptoms are rare, 
though in very bad cases delirium and, especially in young children, 
convulsions may occur. In from three to five days the beginning of the 
second stage of the disease is marked by the development of the erup- 
tion, which almost invariably appears first upon the cheeks and fore- 
head and around the mouth, and spreads rapidly downward over the 
rest of the body. It consists first of minute papules, which are sur- 
rounded by a pale-red, slightly elevated border and become confluent. 
When fully developed the eruption consists of dark-red macules, which 
by the finger can be found to be slightly elevated, and are of irregular 
shape and size, more or less crescentic, dentated, and often fantastically 
arranged in festoons or column-like groups. Under the pressure of the 
finger they lose their color at once, but regain it immediately upon re- 
moval of the pressure. With the appearance of the exanthem the fever 
usually increases, and the catarrhal symptoms become more manifest. 
In from thirty-six to forty-eight hours, however, in favorable cases all 
the symptoms begin to decline, and in from three to six days the fever 
has disappeared, desquamation has commenced upon the face, and a 
rapid convalescence has been entered upon. 

In some cases the eruption of measles is very small and remains dis- 
crete, whilst in others the patches flow together so as to make a uniform 
covering of the surface, which resembles somewhat the rash of scarlet 
fever. Very rarely the measle rash becomes vesicular. 

The departure of measles from the ordinary type is best studied 
under the heads of mild and malignant cases. Of the benign varieties 
the most remarkable is that in which all the symptoms of the disease are 
present except the eruption, producing a disease-picture whose true nature 



104 



GENERAL DISEASES. 



can be recognized only by knowledge that the subject has been exposed 
to the contagion of measles. In a similar way there would appear to be 
certain cases of measles in which the catarrhal symptoms are altogether 
wanting. There is also an abortive form of the disease in which the 
eruption appears with the ordinary symptoms, but fades immediately, 
with a rapid abatement of the fever, and a well- developed convalescence 
by the fifth or sixth day of the disease. These cases can be at once dif- 
ferentiated from those in which there is a sudden retrocession of the 
eruption by the immediate abatement of the constitutional symptoms. 

Among the malignant forms of measles may be placed those cases in 
which the disease develops during the course of some other serious illness, 
as a tuberculosis, or even an acute disorder, like typhoid fever or diph- 
theria. Under these circumstances the course of the measles is very 
frequently irregular, the eruption imperfectly developed, the fever high, 
and the complications excessive. A form of measles which has been 
especially seen in the army, and in children's asylums, is that in which 
from the beginning there is violent dyspnoea with marked cyanosis, and 
usually rapid death from asphyxia. In many of these cases examination 
will reveal the fine disseminated rales of a capillary bronchitis, but 
sometimes the only departure from the norm to be made out is extreme 
feebleness of the respiratory movements. It is to this variety of measles 
that the name of epidemic capillary bronchitis has been given. 

In the ataxic or adynamic form of measles the severe symptoms 
usually develop at the time of the appearance of the eruption. The 
pulse becomes very rapid, the respiration exceedingly hurried, the tem- 
perature rises to 104° or 105° F., and the dry tongue, typhoid face, great 
muscular prostration, and other symptoms of the typhoid state rapidly 
develop. In young children repeated convulsions are frequent and often 
end in coma. In adults, delirium, mild and muttering or fierce and 
maniacal, comes on. Death in such cases may occur in three or four 
days 5 or with the development of natural sleep and a great increase 
in the secretion of the urine the violence of the symptoms may abate. 
In some of these cases there is a sudden disappearance of the eruption, 
with a great increase of the symptoms. A rare form of measles is that 
known as u black measles," with hemorrhage under the skin and into 
the mucous membranes, terminating in death in two or three days. 

Complications. — In measles as ordinarily seen the complications are 
very often much more serious and important than the original disease. 
The most frequent of them are connected with catarrhal irritation of the 
respiratory mucous membrane. Violent nasal catarrh may give rise to a 
serious otitis media ; laryngitis may be followed by so much swelling as 
to produce symptoms of laryngeal obstruction ; whilst actual membranous 
exudation is not very rare in the throat and larynx, and may be asso- 
ciated with the diphtheria bacillus. Bronchitis is almost universal, and 
is especially prone to pass into the small tubes and produce a capillary 



INFECTIOUS DISEASES. 



105 



bronchitis followed by the formation of small infiltrated patches through 
the lungs, which by their confluence may produce wide-spread lobular 
pneumonia. Broncho-pneumonia also occurs. The pulmonary compli- 
cations may develop at any period of the disease, but are more frequent 
and severe during the stage of eruption and also during convalescence. 
They are usually marked by increased fever, rapid respiration, and dys- 
pnoea. Fine sibilant or more commonly fine moist rales may be heard 
upon auscultation through the whole chest, but a very severe dissemi- 
nated lobular pneumonia may exist without dulness of percussion or 
without alteration of the breath- or the voice-sounds : only when the 
patches are confluent do these physical signs of consolidation become 
apparent. When severe pulmonary complications occur in young chil- 
dren the dyspnoea is extreme and convulsions are not rare ; death from 
suffocation may occur during the second or third day. 

In healthy subjects the conjunctivitis rarely ends in suppuration or 
serious trouble, but in delicate children suppurative conjunctivitis, 
diffused purulent keratitis, and ulceration of the cornea are especially 
common. 

Tubercular disease often develops during the convalescence of measles. 
The resistive power of the system seems to be lowered out of proportion 
to the severity of the original disease, whilst the various catarrhal inflam- 
mations afford an excellent nidus for the bacillus. 

Diagnosis. — During the period of invasion the catarrhal symptoms 
separate measles from the ordinary eruptive fevers, but cause the attack 
to resemble very closely one of epidemic influenza. The most important 
difference in the affections is that in grippe the temperature is apt to reach 
its maximum in the first few hours, whilst in measles it mounts steadily 
for two or three days. The eruption of measles is sometimes simulated 
by the rashes produced by copaiba and other drugs, but under such cir- 
cumstances the catarrhal symptoms are wanting, and fever, if present, 
takes a diverse course. (See also Eotheln and Small-pox. ) 

Prognosis. — In healthy children, properly taken care of, measles is 
ordinarily a very trivial affection, almost free from danger to life. On 
the other hand, in some epidemics it has almost rivalled the plague in its 
destructiveness, fifty or even seventy per cent, of the cases ending in 
death. The mortality is excessive between the ages of one and four. 
In civil life, among adults well taken care of, the mortality should not 
be more than three or four per cent. ; in armies and crowded prisons it 
may rise, as at the siege of Paris, to thirty-seven per cent. Race charac- 
teristics are of importance. Death is much more frequent among negroes 
than among whites ; whilst the results of the inoculation of semi-barbarous 
people with the contagion have been frightful. In North America, South 
Africa, and Oceanica, half the population of a whole district has died in 
the course of a few weeks. 

Treatment. — Owing to the great tendency to catarrh, the mildest 



106 



GENERAL DISEASES. 



case of measles should be put to bed aud kept there until convalescence 
is established, and the greatest care should be subsequently exercised 
for some weeks until desquamation is completely over ; exposure may 
cause death. The sick-room should be somewhat darkened so long as 
there is any photophobia, and should be well ventilated, but free from 
draughts. The conjunctiva should be washed once, twice, or oftener 
a day, according to the severity of the symptoms, with saturated solu- 
tion of boric acid ; whilst borax, potassium chlorate, and other local 
remedies should be used for mucous inflammation in the nose, mouth, 
and fauces. The diet should be light but nutritious, consisting of milk 
and milk purees, animal broths, and, as convalescence comes on, milk- 
toast, oysters, sweetbreads, chicken, and other light solid foods. 

In the ordinary case of measles the only medical treatment required is 
the administration of moderate doses of potassium citrate, which has a 
tendency to favor perspiration, increase the secretion of urine, and favor- 
ably affect the bronchial inflammation. If constipation exist, it should 
be immediately relieved. Diarrhoea should not be interfered with so 
long as it is slight ; if it be excessive, bismuth and carbolic acid, or 
other local remedies, may be used. If the eruption be delayed or if it 
retrocede, the patient should be put at once in a hot bath or a hot 
mustard bath (two teaspoonfuls to the gallon), or the hot mustard foot- 
bath should be used. A sudden rise of temperature, or even a very high 
temperature gradually attained, almost invariably indicates the coming 
on of bronchial or pneumonic irritation, and calls therefore for the em- 
ployment of counter-irritation and the appropriate internal remedies. A 
temporary elevation of temperature does no harm, but, as any continu- 
ance of a severe pyrexia (103° F.) is dangerous, it must be met by the 
use of external cold or of antipyretics. Of the antipyretics phenacetin 
is probably the safest, next after it antipyrin. In no case should very 
large doses of these remedies be used. It is safer to reduce the temper- 
ature by means of the bath of the temperature of 90° F., which if essen- 
tial may be further cooled, even as low as 80°. As the pyrexia is very 
seldom urgent, the bath should be used not only cautiously but also with 
slow increase of power, so that no greater application of external cold 
be made than is absolutely essential. After removal from the bath the 
patient should be rapidly dried, and if there be any failure of vitality 
whiskey should be given. 

The treatment of the pulmonic complications of measles does not dif- 
fer from that of similar condition of the lungs arising from other cause. 
Sedative remedies are, however, borne very badly, and stimulants are 
commonly necessary from the first. Small doses of ipecac may be given 
with potassium citrate, but stimulant expectorants, such as ammonium 
chloride, terebene, and oil of eucalyptus, are soon demanded. Extract of 
ergot is sometimes valuable in reducing the congestion ; and the free use 
of hot poultices over the chest is of the utmost value. In malignant 



INFECTIOUS DISEASES. 



107 



measles free stimulation should be employed from the onset, by means 
of whiskey or brandy, raw beef juice, and meat essences. 

ROTHELN. GERMAN MEASLES. 

Definition. — A contagious febrile disease, characterized by mild ca- 
tarrh, a measles-like eruption, and enlargement of the lymphatic glands. 

Etiology. — Eotheln, although long confounded with other exanthem- 
atous diseases, is without doubt distinct. It occurs almost universally 
in epidemics, and is due to a contagion of unknown nature, which is 
capable of being transferred in fomites and is given off by the subject 
from the period of invasion to well- advanced convalescence. 

Symptomatology. — The invasion period of rotheln is short, and 
marked only by slight fever, malaise, nervous disturbances, and some 
conjunctival catarrh. Even at this time, however, pressure upon the 
jugular and subauricular lymphatic glands will usually detect tenderness. 
The eruption is especially prone to develop during the night, and in more 
or less erratic ways. It may appear first on the face or upon the body, or 
on the inner side of the arms, etc. It is more or less polymorphous in 
color and size and form, as well as in dissemination. Upon the trunk, 
and especially upon places where there is continuous pressure, the spots 
may become confluent, whilst upon the hands and feet they are usually 
discrete. The eruption spreads rapidly, reaching commonly its full efflo- 
rescence and beginning to fade in from twenty-four to thirty-six hours, 
and disappearing entirely without desquamation in three days. Its color 
ranges from a pale rose to a deep red ; and, whilst it varies greatly in its 
minute appearance, there are two typical forms, — one in which the spots 
are minutely papular, like measles, and one in which they are large, 
reddish plaque*, suggesting scarlet fever. 

During the stage of eruption the bodily temperature usually remains 
below 101° F., but may rise to 103° ; the conjunctival and nasal catarrh 
persist until convalescence, but are rarely so severe as in true measles. 
The most distinctive feature of the disease is the glandular enlargement. 
This is most pronounced in the occipital, submaxillary, and carotid 
glands, and is often very severe. In some cases, however, the only glands 
apparently affected are those of the extremities or of the trunk, and these 
may not be visibly swollen, although tender upon pressure. The glan- 
dular enlargement does not always disappear with the exanthem, and 
sometimes may be detected two weeks after the first invasion. When 
the eruption has not been severe it is often impossible to demonstrate 
a true desquamation, but a furfuraceous shedding of the epiderm may 
sometimes be detected. 

There is said to be a malignant form of the disease, but usually there 
are no complications and the cases pass rapidly to recovery. 

Diagnosis. — It is affirmed that the eruption in rotheln may exist 
without the enlargement of the lymphatic glands, and the enlargement of 



108 



GENERAL DISEASES. 



the lymphatic glands without the eruption. In such cases the diagnosis 
could be fixed only by a knowledge of exposure to the cause of the disease. 
In our experience the only affection which the disease resembles is measles, 
from which we believe it is especially separated by the lymphatic enlarge- 
ment and tenderness, as well as by the mildness of the catarrh and of the 
general symptoms, and by the polymorphic character of the eruption. 

Treatment. — Rarely is other treatment required than simple nursing. 
Any symptoms which may arise should be met on general principles. 

VARICELLA. CHICKEN-POX. 

Definition. — A specific contagious fever, occurring chiefly in chil- 
dren, and characterized by the presence of a vesicular eruption. 

Etiology. — Various organisms have been isolated from the lymph of 
the vesicles of chicken-pox, and Bareggi asserts that he has discovered an 
ovoid micrococcus which exists in the white blood- corpuscles and whose 
cultures are capable of producing varicella in infants j whilst Pfeiffer 
has found an amoeba-like parasite in the vesicular lymph. Varicella is 
certainly distinct from all other diseases, and is entirely incapable of pro- 
tecting from small-pox or other affections. It occurs almost exclusively 
among children. 

Symptomatology. — The period of incubation is from ten to fifteen 
days, followed by a period of invasion which in most of Steiner's in- 
oculation experiments lasted four days, but which in the natural disease 
is ordinarily much shorter. The symptoms usually consist simply of a 
slight fever and malaise, although there are cases in which violent vomit- 
ing, delirium, very high temperature, convulsions, and excessive dys- 
pnoea develop to an alarming degree. There is, moreover, no distinct 
relation between the severity of these primary symptoms and the gravity 
or prolongation of the whole sickness. The eruption usually first appears 
upon the trunk, only in rare cases upon the face, and is first a macule, 
then a transparent vesicle which becomes opaque and finally forms into a 
crust. The macular stage is so short that it is often overlooked. The 
vesicles are brilliant, rarely umbilicated, surrounded by a reddish areola, 
and varying in size from a tenth to a quarter of an inch : especially when 
scratched by the child, they may leave distinct, ugly scars. Fresh groups 
of the eruption may appear for several days, so that various stages of the 
pock coexist side by side. In cachectic cases the varicellar eruption is 
purpuric, and may be ecchymotic ; even gangrenous ulcers sometimes 
result. The eruption may occur upon mucous membranes, producing a 
simple or an ulcerated stomatitis, angina, tracheitis, conjunctivitis, or 
vulvitis. During the eruptive stage there is generally a mild fever. In 
ordinary varicella severe complications are rare, though nephritis does 
occasionally occur. In purpuric or malignant varicella various hemor- 
rhages, local gangrene, pneumonia, pleurisy, and abscesses have been 
noted ; whilst severe nephritis is not infrequent. 



INFECTIOUS DISEASES. 



109 



Diagnosis. — Varicella can usually be distinguished from varioloid 
without difficulty by the absence of serious prodroniic symptoms $ by the 
appearance of the first vesicles upon the trunk ; by the absence of the 
hard, shotty feeling of the papules, or of umbilication in the vesicles ; and 
by the failure finally to develop pustules. The varicella pocks are also 
more bleb-like, and the areolation around them is not so deep. When 
the pock of varicella becomes confluent and in some places umbilicated, 
the diagnosis may for a time be very difficult, especially if there be no 
distinct history of the earlier stages of the attack. Acute pemphigus, 
varicelliform syphilides, and certain other skin affections occasionally 
closely resemble varicella, but can usually be distinguished without dif- 
ficulty by being apyretic or by the slow development of the vesicles. 

Prognosis and Treatment. — Varicella ordinarily requires no fur- 
ther treatment than some restrictions of diet and of exposure. In the 
rare malignant cases the prognosis may be grave, whilst the treatment 
should be that of malignant febrile attacks of other nature. 

VARIOLA. SMALL-POX. 

Definition. — An acute contagious fever, characterized by an eruption 
whose unit is at first a hard papule, then an umbilicated vesicle, then a 
pustule, and finally a crust. 

Etiology. — The cause of small-pox is a contagium which is probably 
an organism. Late in the disorder secondary septic infection is very 
prone to occur, so that various species of staphylococcus, streptoccocus, 
and even a saccharomyces, have been found in different portions of the 
body. The nature of the original virulent organism still remains doubt- 
ful. Klebs has described a tetracoccus, whilst Pfeiffer and Van der 
Loeff affirm that there is a sporozoon. For the transmission of the con- 
tagium contact is not necessary ; the fact that the crusts, which in China 
are preserved for the purposes of inoculation, retain their activity for two 
years, shows how tenacious of life the germ is j and any form of fomites 
suffices. The contagium chiefly finds entrance into the system through 
the respiratory organs, and there is much evidence to show great resistive 
power in the digestive organs. It certainly exists in enormous quanti- 
ties in the pustules and scabs ; but it probably escapes from the body 
with all the excretions, and is abundantly given off during the stage of 
invasion before the appearance of the eruption. Legroux and others 
have reported severe epidemics which originated in cases which died 
during the prodromic stage. The maximum activity of the contagium is 
said to be at the time when the pus-formation is most abundant. 

Predisposing causes are of little importance in the history of small- 
pox ; it attacks all ages and both sexes. Very few persons, unless pro- 
tected by previous attacks, are insusceptible to the poison, though there 
appear to be certain families in which there is a distinct hereditary im- 
munity. Certain races, notably the negroes, seem to be more susceptible 



110 



GENERAL DISEASES. 



than others ; but the statements that have been made that other races, 
such as the Hindoos and the Australians, are insusceptible, is incorrect. 
Owing probably to the complete lack of protection by previous attacks, 
aboriginal tribes such as the North American Indians are liable to be 
reduced almost to extinction by small-pox epidemics. When inocula- 
tion was practised, the period of incubation was almost invariably from 
eight to nine days; the more usual time is from nine to ten days, but 
it varies from eight to fourteen and in rare cases even twenty-five days. 

Morbid Anatomy. — The skin presents the remains of the eruption 
either as crusts, pustules, or ulcers, which in hemorrhagic cases are infil- 
trated with blood. Pustules or ulcers may also be found in the mouth, 
pharynx, and oesophagus, and in the upper air-passages. In the latter a 
fibrinous exudation may be present. The dependent portions of the lungs 
are often collapsed, injected, and cedeniatous, and patches of lobular pneu- 
monia or broncho-pneumonia are frequent. The heart is flaccid, of a pale- 
gray color from granular degeneration of its muscular fibres. The liver 
and kidneys also show evidences of parenchymatous degeneration, and the 
spleen is enlarged and soft from acute hyperplasia. Minute necrotic foci 
have been found by Weigert in the liver, spleen, kidneys, and lymphatic 
glands, and Chiari has described multiple minute spots of a grayish- 
yellow color rapidly tending to become necrotic. Weigert and Bowen 
have found focal necroses in the lungs, liver, spleen, kidneys, and lymph- 
glands. Chiari and Mallory observed similar lesions in the testes and 
bone-marrow. 

In hemorrhagic small-pox the above-described changes are lacking, 
since time is required for their development. Characteristic are hemor- 
rhages in the skin, in the mucous and the serous membranes, within the 
muscles, joints, and bone-marrow, and in the loose connective tissue of 
the mediastinum and along the spine. Hemorrhages are rare in the vis- 
cera, although present in the renal pelvis and calices and in the uterine 
mucous membrane. The heart and spleen are dense, of a dark reddish- 
brown color, somewhat translucent. Nothing abnormal is found in the 
appearance of the liver or kidney. 

Symptomatology. — Small-pox is among the more consistent of the 
eruptive fevers, but for the purposes of study it may be divided into 
Simple small-pox (Variola vera), Malignant or Hemorrhagic small-pox, 
and Varioloid or mild small-pox as modified by previous attacks. 

Simple small-pox is divided into three varieties : the Discrete, in which 
the pustules remain distinct from one another ; the Coherent, in which 
though at first distinct they finally come in contact and join at the edges ; 
and the Confluent, in which almost from the beginning they run together. 
It must be remembered that these varieties represent simply distinct 
degrees of intensity, and that they are not sharply separated from one 
another. 

The course of an ordinary small-pox is divided into four periods : first, 



INFECTIOUS DISEASES. 



Ill 



that of invasion ; second, that of eruption ; third, that of suppuration ; 
fourth, that of desiccation and desquamation. 

Invasion. — The onset of small-pox is sudden and accompanied with a 
violent rigor or very frequently with a series of rigors, which may last 
many hours. Fever sets in immediately, and the temperature may rise 
within a day to 104° or 105° P. The pulse is rapid, fall, rarely if ever 
dicrotic, and sometimes has a distinct hardness. Vomiting always occurs, 
and is commonly severe and repeated. The matters vomited are in no 
way characteristic, consisting of the stomachic contents and mucous bile. 
There is often a very painful sense of epigastric constriction, and in most 
cases acute constipation exists. The skin and the mucous membranes 
are dry. The nervous phenomena are very pronounced ; not rarely in 
the young child the chill is replaced or accompanied by convulsions, 
and the neuralgic pains are in their severity almost diagnostic of the 
fever. Headache and backache are constant and extreme. The latter 
is especially in the lower lumbar region, sometimes spreading upward 
even to the neck, and radiating into the legs and more rarely the arms. 
It is often associated with a sense of difficulty of respiration or of feel- 
ing of weight upon the chest, which may rise to a violent dyspnoea, with 
a great acceleration of the respiratory movements, that cannot be ex- 
plained by any condition of the lungs. Delirium is very common j in the 
mildest attacks it consists simply of a little wandering at night 5 in the 
more severe and adynamic cases it may be hallucinatory, and is often so 
associated with tremors as to present an appearance of delirium tremens. 
In the severest forms there may be the muttering delirious unconscious- 
ness of profound exhaustion, or a wild and even violent mania. 

Often on the second or third day initial rashes appear, especially 
affecting the distribution of the abdominal nerves, — that is, of the nerves 
arising from that portion of the back which suffers most from aching 
pains. The eruption may resemble that of scarlet fever or of measles, or 
it may be erythematous or erysipelatoid ; sometimes it suggests roseola, 
or even an urticaria-like localized oedema ; if it be purpuric or ecchy- 
motic it indicates the hemorrhagic form of the disease. It is usually 
from one to two days in its development, and fades in about the same 
time, though the scarlatinal rash, which is more tenacious than the other 
forms, may last six days. The initial rash occurs in about one-sixth of 
the cases, but is more frequent in some epidemics than in others. It is 
usual for the subsequent characteristic variolous eruption to be least 
abundant in those parts of the body which have been especially occu- 
pied by the initial rash. 

Eruption. — From the third to the fourth day in a case of discrete 
small-pox there is usually abatement of the constitutional disturbances, 
with the appearance upon the forehead, especially near the roots of the 
hair, of small red spots that rapidly spread to the face and then to the 
body and limbs, which in from twenty- four to thirty -six hours are com- 



112 



GENERAL DISEASES. 



pletely covered. The eruption quickly changes into distinct papules, 
and these again into vesicles, which are usually fully formed upon the 
face by the third day of the eruption, but on the extremities do not arrive 
at this degree of maturity until two or three days later. The vesicles are 
of various sizes, always, however, in the discrete form larger than in the 
confluent variola, and very distinctly umbilicated except upon the face. 
They are surrounded by a red areola, and on the face are usually opaque 
and purulent by the seventh or eighth day. During the stage of eruption 
the mucous membranes of the conjunctiva, mouth, pharynx, and larynx, 
vulva, and prepuce are intensely red, and have frequently on them an 
eruption which is usually proportionate in severity to that upon the 
surface of the body. The mucous membrane vesicles are small, often 
brilliant, and apt to leave small round erosions. 

The defervescence at the beginning of the period of eruption is often 
abrupt, and the temperature continues low until about the seventh day. 

Suppuration. — The period of suppuration usually begins from the 
seventh to the eighth day, and lasts about four days : during this stage the 
vesicles are converted into swollen pustules, accompanied often by great 
subdermal swelling, excessive irritation of the skin, and great pain upon 
movement. In severe cases violent conjunctivitis, excessive salivation, 
dysphagia, dyspnoea from oedema of the glottis, or bronchial inflamma- 
tion, may occur. The fever during this period is pronounced, headache 
is usually present, and the sleep is unquiet and not rarely interrupted by 
delirium. 

The fourth period, that of desiccation, may be considered to commence 
at the eleventh day and to last from ten to twenty days or even longer. 
On the face, and sometimes on other portions of the body, the pustules 
break, discharging their contents so as to make a purulent mask, or each 
pustule in mild cases may form its own distinct scab. The surface, as 
the scabs fall off, is left of a reddish-wine color, often excoriated or 
ulcerated, so that cicatrices of various form and appearance remain after 
convalescence. 

At any time, during even a discrete small-pox, various complications 
may set in : usually, however, they are wanting. During the stage of 
invasion there is habitually an increase in the specific gravity of the 
urine, which may rise to 1075, and is largely due to extreme elimination 
of urea, though extractives, creatinin, xanthin, tyrosin, indican, and the 
sulphates are augmented ; the chlorides are diminished. During the 
stage of eruption and suppuration, however, the urea diminishes, while 
the chlorides are greatly increased. Defervescence is often accompanied 
by a critical discharge of uric acid. 

During the stage of invasion in confluent small-pox the symptoms differ 
from those of the ordinary form only in their much greater intensity, 
and in the tendency, which is especially seen in children, to diarrhoea. 
The eruptive stage is especially marked by the failure of the constitu- 



INFECTIOUS DISEASES. 



113 



tional disturbances to subside, and by the peculiarities of the eruption. 
The whole face becomes excessively swollen j an erysipelatoid rash ap- 
pears $ whilst the papules are in enormous number and rapidly coalesce, 
so that in the vesicular condition the eruption seems to be bullous. In 
certain parts of the body, especially in the lower abdomen, the papules 
are distinct from one another, but they are always smaller and more 
numerous than in the true discrete variety of the disease. The mucous 
membranes suffer greatly : salivation, glossitis, dysphagia, aphonia, dys- 
pnoea, diarrhoea, and dysuria are common symptoms. The fever, though 
it may abate for two or three days, never disappears, and the pulse 
remains frequent. During the period of suppuration the swelling of the 
surface becomes enormous, the features of the face almost disappear, the 
eyes being closed, whilst the movements of the swollen extremities are 
extremely painful. If the patient survive, desiccation begins about the 
eleventh day, but the fever persists, and rarely disappears until the 
fourth week, by which time the face is usually desquamating. Death 
may occur at any time during the disorder : it may be due to adynamia 
and be preceded by violent delirium and coma, or may be the result of 
asphyxia, produced by a rapid congestion, by a bronchial pneumonia, or 
by an oedema of the larynx. Not rarely it is the result of the septi- 
caemia ; sometimes it is due to a sudden cardiac failure the result of a 
myocarditis. 

In Malignant, Hemorrhagic, or Black Small-pox the stage of invasion 
is usually very short, accompanied with very violent vomiting, anxiety, 
dyspnoea, horrible backache, and epigastric constriction, whilst the rash 
which precedes the eruption is more constant and severe and has a much 
greater tendency to be purpuric than in the ordinary disease. The hem- 
orrhages usually appear about the fifth day, first as petechial spots, then 
as phlyctsenulse and subconjunctival ecchymoses, accompanied by violent 
epistaxis, hematuria, and at last bloody discharges from the mouth, in- 
testines, uterus, bronchial tubes, and ears. During the whole course there 
is great adynamia, with rapid feeble pulse, heavy malodorous breath, not 
rarely paraplegia with retention of urine, various anaesthesias or hyper- 
esthesias, diphtheroid exudations, tympanites, and sometimes enlarge- 
ment of the liver and spleen. The eruption is always discrete, and of a 
brownish or black color, whilst the vesicles fill with blood and go into 
pustulation. The temperature is at no time very highly elevated. De- 
lirium and convulsions and terminal coma are common, but sometimes 
consciousness is retained almost to the end ; death occurs from syncope 
or asphyxia. 

In foudroyant cases the end may be reached before the appearance 
of any rash ; more frequently it occurs after the rash, but before the 
specific eruption has been well formed. In less malignant cases the 
hemorrhage may not begin until pustules are well developed. 

Diagnosis. — In the suddenness of invasion small-pox may at first 

8 



114 



GENERAL DISEASES. 



resemble pneumonia, but is to be distinguished at once by the absence 
of physical signs and by the intensity of the backache. Owing to the 
character of the initial rashes, not rarely mistakes of diagnosis between 
it and scarlet fever or measles have been made. It is to be distinguished 
from scarlet fever by the absence of sore throat, and by careful atten- 
tion to the minute characters and especially to the topography of the 
initial rash, which in small-pox is always limited in its distribution, is 
especially abundant on the lower abdomen, and rarely, if ever, appears 
upon the face. The rash of measles appears later than does the initial 
rash, and differs also in its distribution. Further, in both measles and 
scarlet fever the backache is never so severe as in small-pox. Never- 
theless, although the differences seem so clear, yet cases do arise in which 
the diagnosis must for a time remain uncertain, requiring the practi- 
tioner to wait for the appearance of the small shot-like papules on the 
upper forehead before sending the patient to the hospital. In rare 
cases of measles there may be some papulation, but the papules lack the 
intense hardness of those of small-pox. 

From small-pox in the vesicular stage varioliform syphilide, which is 
often accompanied with a pronounced fever, is to be differentiated by 
the slowness of -its evolution, by the absence of backache, and by the 
fact that the temperature does not fall on the appearance of the eruption. 
There is also a variolous form of acne, but it is apyretic and develops 
slowly. Chicken-pox is to be distinguished from varioloid and other mild 
forms of small- pox by the oblong form and greater size of its bullae, by 
their irregular dissemination, by the absence of distinct umbilication and 
of suppuration, and by the lack of severe constitutional disturbances. 
There are, however, cases in which for a time the diagnosis between 
chicken-pox and very mild varioloid must remain in doubt. 

The severity and universality of the hemorrhages and the abundance 
of the petechise distinguish malignant small-pox from malignant scarlet 
fever, cerebro- spinal meningitis, and other similar affections. If death do 
not occur before the fourth day, the papules, even if they be not plainly 
apparent in the deeply discolored skin, can be felt in the region of the 
upper forehead along the edge of the hair. 

Prognosis. — The prognosis in small- pox varies with the epidemic 
and with the age. In the very young almost all the cases die. Alco- 
holism, old age, general feebleness of constitution, and previous chronic 
disease, increase greatly the danger. Taking all the cases, the mortality 
of variola in the unprotected is from forty to fifty per cent, in different 
epidemics. Pregnancy, especially in its later stages, increases the fatality. 
Abortion is almost invariable after the third month, is accompanied with 
great hemorrhage, and usually ends in death. The foetus in a majority 
of cases suffers from the disease. 

Treatment. — Every case of small-pox should be isolated from the 
first moment at which suspicion of the nature of the disease is aroused. 



INFECTIOUS DISEASES. 



115 



Free, even violent, ventilation of the room should be insisted upon, so as 
to prevent any condensation of the poison. Further, everything which 
is capable of affording a resting-place for the poison, such as carpets or 
hangings, should be removed from the room, whilst the personal and bed 
linen should be changed frequently, and always dropped at once into a 
solution of corrosive sublimate or into boiling water. The surface of the 
body should be frequently bathed, with the free use of carbolic acid soap, 
and after the bath the water should always have added to it sufficient of 
corrosive sublimate (1 to 500) or of carbolic acid (1 to 200) to destroy 
all germs. All discharges from the body should be immediately disin- 
fected. (See Typhoid Fever.) 

During the whole course of the disorder, unless there be a tendency 
to subnormal temperature, the patient should be lightly covered in the 
bed. The diet should be easily digested but highly nutritious, milk, 
strong broths, raw eggs, and similar foods being relied upon. It must 
be remembered that the suppurative process is very exhaustive, and 
the patient should be fed up to the fall power of digestion. The use 
of baths is of the greatest importance ; in the stage of invasion the hot 
bath will frequently relieve the pains, whilst whenever the fever is high 
the cold bath will reduce the temperature and often moderate the ner- 
vous disturbances. If there be delirium and subsultus, with a temper- 
ature of over 102.5° F., the bath of 80° F. may be used every three or 
four hours, the temperature of the water being reduced if it be not low 
enough to cool the patient. Symptoms must be met as they arise. 
Opium is especially useful in the period of invasion, and when there 
is much vomiting should be given in the form of suppositories. It is 
also serviceable when in the advanced stages there is great irritation 
from the suppurating skin, or when there is insomnia combined with 
delirium. 

Laxatives in most cases are required from the beginning ; but if diar- 
rhoea should exist, opium, bismuth, salol, and similar remedies may be 
employed. Chloral given in small doses along with opium and hyoscine 
is sometimes useful in controlling maniacal outbreaks. As prostration 
comes on and increases, alcoholic stimulants, strychnine, and other stimu- 
lant remedies should be used. It is doubtful whether in malignant small- 
pox any drugs have perceptible power for good ; nevertheless, various 
stimulants may be freely used, and an attempt may be made to check 
hemorrhage by the use of ergot and other haemostatic remedies, though 
it would seem more rational to struggle only for euthanasia by the use 
of opiates. 

As the inflammation and ulceration of the skin in variola not only are 
a source of immense suffering and after- disfiguration, but often play an 
important part in the production of a fatal exhaustion, the local treat- 
ment is a matter of great importance. Numerous plans have been tried 
from time to time, but experience seems to show that many of them are 



116 



GENERAL DISEASES. 



harmful, and few, if any, of value. Opening the pustules and forcing 
out their contents ; altering the disease-processes by the application of 
nitrate of silver or iodine or other substance to the individual pustule ; 
the employment of mercurial, iodinic, and other alterative ointments, and 
all similar procedures, are generally condemned by recent authorities. It 
would seem, however, that there is some truth in the old belief that light 
fosters the development of the pustules : hence it is well to protect the 
face and hands by the constant application of patent lint.* The local ap- 
plication of cold wet lint is generally very grateful to the patient, and 
some good may be hoped for from the addition to the water of antiseptics, 
such as salol (1 to 10), sodium salicylate (1 to 10), boric acid (1 drachm 
to the pint), corrosive sublimate (1 to 5000), and carbolic acid (1 to 
200). The sensations of the patient should be the guide in regard to the 
temperature of the compresses, and also, in a measure, to the strength of 
the solution. When tepid applications are preferred to cold they should 
be used. Very grateful and very useful during the stage of suppuration 
and desiccation are prolonged warm baths, in which the patient is im- 
mersed for two or three hours once in the twenty-four hours, and by 
which the local inflammation is often greatly reduced. As a substitute 
for these baths, in France the person is sometimes fully washed two to 
four times a day with a warm solution of corrosive sublimate (1 to 1000). 

VACCINIA. COW-POX. 

Definition. — An eruptive disease of the cow, the virus of which is 
capable of producing in man a pock, associated with constitutional dis- 
turbance, and having protective influence against small-pox. 

In 1798, Edward Jenner found that in Gloucestershire milkmaids and 
others accidentally inoculated by the cow-pox were afterwards insuscep- 
tible to small-pox, and was thus led to his immortal discovery. It does 
not seem worth while to occupy space in this volume with statistics 
proving the value of vaccination. The fact that before the days of Jen- 
ner small-pox killed in England as many persons as all other diseases put 
together, in contrast with the present mortality from small-pox, is suffi- 
cient. If thorough vaccination and revaccination of whole communities 
were possible, small-pox would almost disappear. The mortality-rate of 
the mild forms of variola (varioloid) which occur in those who are pro- 

* The demonstrations of Unna, Hammer, Widmark, and others that it is the 
chemical rays of the sun, especially the ultra-violet rays, which irritate the skin and 
produce " sunburn," led Finsen to try the effect of completely excluding these rays 
from the rooms of small-pox patients, and his assertion that the severity of the 
eruption is greatly abated has been confirmed by Feilberg, Svendsen, and other 
Scandinavian doctors. The red sheets which protect all the doors and windows 
should, if of muslin, be of four thicknesses, though heavy flannel is preferable : red 
glass does very well if it is thick and dark. The chemical rays must be shut out as 
absolutely as in a photographic dark room, and only protected lamps (red) allowed. 
Further, it is essential that the treatment be begun during the stage of invasion. 



INFECTIOUS DISEASES. 



117 



tected by vaccination is not more than eight per cent., while in the un- 
vaccinated it probably exceeds forty per cent. W. M. Welch's mortality 
statistics (Municipal Hospital of Philadelphia) give, in persons with good 
cicatrices, eight per cent. ; with fair cicatrices, fourteen per cent. ; with 
poor cicatrices, twenty-seven per cent. ; post- vaccinal cases, sixteen per 
cent. 5 unvaccinated cases, fifty-eight per cent. 

Concerning the explanation of the immunity conferred by vaccination 
there has been almost endless discussion. Whilst nothing can be consid- 
ered positively determined in the matter, it is extremely probable that 
cow-pox is variola which has been altered by its passage through the 
cow but yet has retained the protective power of the original disease. 
It is true that Chauveau, of the Lyons Commission, Warlomont, Berthet, 
and others have failed in their efforts to produce the vaccine disorder 
by the inoculation of cows with matter from variolous pustules ; but 
more recent investigators, especially Pfeiffer, Fischer, Eternod, and Hac- 
cius, agree in affirming that if the liquid from the small-pox vesicles be 
brought in contact with a large and thoroughly denuded surface in the 
cow there will be produced a pustular eruption which after the second or 
third generation of reinoculation becomes identical with that of cow-pox 
and is able to produce typical vaccine disease in infants. 

Stephen C. Martin states that the germ of cow-pox is an organism 
which is in one stage of development a coccus and in another a bacillus, 
and that by inoculating with pure cultures of this organism he has pro- 
duced typical cow-pox in the calf and also in man. 

Vaccination in man may be produced with lymph taken from the 
human vaccine vesicles, with the scab which follows vaccination, or with 
lymph taken from the cow. Injurious effects from vaccination are ex- 
tremely rare, but syphilis and other constitutional or bacterial diseases 
may be transmitted. Very severe epidemics of vaccino-syphilis, the 
product of a mixed infection, have occurred, especially in Europe. 

The vaccine disease as produced by animal material is more severe 
than that caused by humanized lymph, but it is probably also somewhat 
more protective, and, as by its use all danger of specific infection is 
avoided, the employment of humanized vaccine is ordinarily unjustifiable. 
When animal virus cannot be obtained, the greatest care should be taken 
in collecting the human vaccine to see that it is from healthy infants 
who are free from acquired or hereditary taint, and that it is collected 
without admixture with blood or possible septic matter. 

So far as the protection is concerned, it makes no difference upon what 
part of the body the vaccination is performed, but in female infants of 
the richer classes the leg should be selected, for jesthetic reasons. The 
skin, after it has been thoroughly washed, first with warm water and 
soap and then with alcohol, and dried, should be very superficially cross- 
hatched with a dull lancet or the ivory point, and the moistened or liquid 
lymph be well rubbed in : care should be taken to see that there is no 



118 



GENERAL DISEASES. 



bleeding. After quiet drying, the spot may be protected by a clean 
linen handkerchief, or, if there be any special reason for fearing infec- 
tion, with a dossil of antiseptic cotton. 

Vaccination in a fresh subject is followed in from one to twenty-four 
hours by a reddish blush, with, in the centre, a papule, which increases 
and becomes vesicular, so that by the fifth or sixth day it is a well-formed 
orbicular vesicle. By the eighth day the vesicle is distended with limpid 
fluid, and has a hard margin, a marked umbilication, and a wide red 
area. Usually from this time the inflammation begins to subside ; by the 
twelfth day the vesicle is opaque, beginning to dry ; by the fifteenth 
day there is formed a distinct brownish scab, which falls off on from the 
twenty-first to the twenty-fifth day, leaving a large circular or irregular, 
deeply pitted scar. Fever is usually present from the third to the ninth 
day, varying in severity and duration in different cases, and often in 
children associated with pronounced nervous irritability. Swelling of 
the neighboring lymphatic glands is common, and may be troublesome. 
In unhealthy subjects the vaccine vesicles may be accompanied with 
great inflammation and end in ulceration. Local dermatitis and ery- 
thematous or roseolous rash may accompany the vaccination, probably 
without being the result of any special infection ; but when erysipelas 
or septic cellulitis or contagious impetigo or tetanus results, as has oc- 
curred, there has been a double inoculation. 

Usually the subsidence of the pock ends the disorder, but in rare cases 
secondary pocks appear in the vicinity of the original vaccination, or 
even in distant parts of the body. In feeble children a fatal result is 
possible. 

Vaccination does not confer an absolute protection against small-pox ; 
the susceptibility slowly increases as the years go by, so that revaccina- 
tion is essential at not longer periods than eight or ten years. Indeed, 
whenever any person is exposed to an epidemic of small-pox, revaccina- 
tion should be insisted upon. The vesicle in revaccination is usually 
smaller than that of primary vaccination, and accompanied by less 
induration and resultant scar. In cases of failure to "take" there 
should be repetition of the vaccination almost indefinitely if there be 
positive exposure to small-pox. 

MILIARY FEVER. 

Definition. — A contagious malady, characterized by an eruption 
of miliary vesicles, ending in desquamation. 

Although during the Middle Ages epidemics of the English Sweat- 
ing Disease or the British Plague, as it was termed on the continent 
of Europe, carried off large numbers of people (eight thousand, it is 
said, in eight days in Augsburg alone), of recent years the disease has 
occurred rarely and in limited localities : so far as we are aware, it has 
not been reported at all in North America. 



INFECTIOUS DISEASES. 



119 



The period of incubation is from one to five days. With or without 
prodromes, suddenly or more slowly, the patient passes into a condition 
of great weakness, with high fever, excessive sweating, and various 
nervous symptoms, which occur especially in nocturnal paroxysms. 
Violent headache, sudden attacks of excessive dyspnoea, with agonizing 
constrictions in the throat and chest, or even in the abdomen, intense 
insomnia, mild or sometimes raging delirium, and wide-spread coldness 
of the extremities, are among the most characteristic symptoms of the 
night attacks, and may occur during the day. After from one to four 
days, rarely as long as a week, the eruption appears, with an increase 
of the fever, and especially of the nervous symptoms. This eruption 
is twofold in character, — in exanthem, which may resemble that of 
measles, or scarlet fever or be hemorrhagic or purpuric, and a miliary 
rash, which consists of minute acuminated papules, rapidly developing 
into vesicles, which may be very small or by coalescence may be formed 
into bullae. Twenty -four hours are usually sufficient for the completion 
of a vesicle : on the third day desiccation begins, followed about the 
fifth day by a furfuraceous or sometimes a massive desquamation. The 
urine, which is ordinarily scanty during the attack, often becomes, by 
the thirteenth or fourteenth day, suddenly very excessive, and the dis- 
ease may break up with a urinary crisis. Convalescence is apt to be 
long and uncertain. 

The mortality-rate varies greatly in different epidemics. It has risen 
as high as thirty-three per cent., but in the recent epidemics it seems to 
have been about two per cent. The treatment consists in proper nursing 
and hygiene, the use of cold baths as they are indicated, and the meeting 
of the various symptoms as they arise. 

TYPHOID FEVER. 

Definition. — A specific fever, due to the presence of a peculiar 
bacillus, and running a course of from three to four weeks, with fever, 
a rose- colored eruption resembling flea-bites, and cerebral, pulmonary, 
and abdominal symptoms, and accompanied by lesions of Peyer's patches, 
of the spleen, and of the mesenteric glands. 

Etiology. — Typhoid fever is due to a short, actively motile bacillus, 
originally discovered by Eberth and by Gaffky. This bacillus is very 
closely allied to the bacillus coli communis, from which it is often dis- 
tinguished with great difficulty. It is killed by a temperature of 60° C, 
but is capable of resisting repeated freezing and thawing. It has been 
known to retain its vitality after having been buried for nearly six 
months, and probably can so live for years. In the body it especially 
develops in Peyer's patches, in the mesenteric glands, and in the spleen, 
but it has been demonstrated in the liver, in the kidneys, and in other 
organs. As ordinarily inoculated, it usually fails to produce in the lower 
animals any series of symptoms or any lesions comparable to those of 



120 



GrExSTERAL, DISEASES. 



typhoid fever in man, but, according to Sanarelli, when rabbits, guinea- 
pigs, and mice have been previously poisoned with the growth-products 
of bacterium coli commune and certain other saprophytes, a rapid infec- 
tion is produced by inoculation with the typhoid germ ; and Alessi asserts 
that typhoid fever can readily be produced in guinea-pigs and rabbits 
which have been caused to breathe for some time the gaseous products of 
organic decomposition. The bacillus is discharged in great numbers with 
the faeces from persons suffering from typhoid fever, and probably also 
escapes to some extent with the urine ; and it is alleged that it has been 
found in the saliva. 

The life-history of the typhoid bacillus outside of the human body is 
known only in very small part. In the laboratory the cultures can be 
propagated almost indefinitely, but appear to lose their pathogenic power. 
Left to themselves, in sewage, in milk, and in other organic mixtures the 
bacilli grow rapidly at first, but are soon destroyed by other bacilli. Air 
and sunlight hasten the destruction of the fever germ. ~No spores have 
as yet been discovered, though they probably exist. 

The bacillus probably always infects the human individual through 
the intestinal tract, which in the majority of cases it reaches in the drink- 
ing-water 5 although in numerous instances it has been carried by infected 
milk, and some very severe epidemics have been produced by eating 
oysters which had been planted near the discharging mouths of sewers. 
It is also probable that the bacilli may be carried upon the hands to the 
mouth, as typhoid fever is very frequent among laundresses who have 
washed the clothing of patients. 

It is evident that, whilst the bacillus is always the immediate exciting 
cause of a typhoid fever, the predisposing causes are of the most serious 
importance ; else why is it, as Peters asked, that when a million of people 
are drinking the infected waters of the Seine, only a comparatively few 
are affected ? Typhoid fever is undoubtedly much more frequent in the 
late summer and autumn months than in winter and spring, in the 
southern temperate zone than in other climates, and after hot, dry sum- 
mers than when the ground- water is high ; but, as it occurs in every 
climate, at all elevations, and in all sorts of weather, it is probable that 
these circumstances are simply factors in favoring the development of 
the organism, and not predisposing causes. Sex is without influence ; 
age is of more importance, as the disease is comparatively rare under fif- 
teen and over thirty years, though it may occur in the youngest infant or 
in the oldest adult. We have seen it at three months, and it has been 
discovered in the foetus. 

The influence of over-crowding, of filth, and of exposure in the pro- 
duction of typhoid fever is not pronounced, but it is probable that what- 
ever lowers the vital power of the human individual lowers the capa- 
bility of resisting the typhoid bacillus, and it would seem that a certain 
immunity is acquired by habitual exposure to the bacillus in a not very 



INFECTIOUS DISEASES. 



121 



virulent form. At least this is the most plausible explanation of the 
notorious fact that young people moving from the country into cities are 
attacked with typhoid fever in many times larger proportion than are 
the older inhabitants of the cities. There would appear, also, to be an 
hereditary susceptibility or lack of susceptibility to the attacks of the 
germ, as certain families are especially prone to be attacked, whilst 
others escape through successive generations. Pepper believes that in- 
testinal catarrh strongly predisposes by affording a nidus of growth to the 
organism. 

Morbid Anatomy. — The lesions characteristic of typhoid fever are 
in the intestine and in the mesenteric lymphatic glands. The many alter- 
ations to be found elsewhere in the body are chiefly dependent upon the 
infectious nature of the disease and the variations in its course. 

The intestinal alterations are those dependent upon the swelling, ne- 
crosis, and sloughing of the lymphatic glands, — namely, the solitary fol- 
licles and Peyer' s patches. A hyperplasia of the cells takes place, pro- 
ducing an enlargement of the follicles or groups of follicles, which assume 
an opaque gray color and a soft consistency. This condition, to which 
the term medullary infiltration is applied, continues throughout the first 
ten days, gradually increasing in extent and involving more or less of the 
follicles and Peyer ' s patches, especially from the ileo-csecal valve upward. 
In some cases these alterations are limited to the ileum, — ileo-typhoid, — 
in others to the lymphatic follicles of the colon, — colo-typhoid ; — and in 
still other cases the lymphatic follicles of both ileum and colon may be 
affected. The mucous membrane of the affected portion of the intestine 
is swollen, injected, and somewhat opaque from the associated catarrhal 
inflammation. 

As the infiltration extends and compression of the blood-vessels oc- 
curs, and perhaps also on account of the direct action of the bacteria 
present, necrosis takes place in the inflamed follicle or Peyer' s patch, in 
the latter often in several places. With the increase of the necrosis, 
which is favored by a cellular infiltration of the perifollicular tissue, more 
or less of the enlarged follicle or Peyer' s patch forms an opaque yellow 
or brown slough, discolored by intestinal contents or extravasated blood, 
and surrounded by a line of demarcation, the tissue limiting which is 
swollen and injected, sometimes gangrenous. At a later stage of the 
inflammatory process the slough is detached entire or in part, gradually 
or rapidly, exposing the deeper layers of the mucous membrane, the mus- 
cular coat, or the subperitoneal fibrous tissue. Necrosis of the inflamed 
follicles takes place during the latter half of the second week, while the 
detachment of the sloughs usually occurs during the third week. The 
inflamed Peyer' s patch may also undergo resolution, with absorption of 
the hyperplastic cells, a trabeculated meshwork enclosing depressed spaces 
being left, the mucous membrane covering which is often perforated (re- 
ticulated patches). When absorption occurs, a flaccid, cederaatous, some- 



122 



GENERAL DISEASES. 



what translucent mucous membrane remains, its outline corresponding 
to that of the patch. This termination in resolution of the inflamed 
patches may be evident after years by the presence of groups of pig- 
mented specks, the shaven beard appearance. 

Healing of the ulcers begins during the fourth week and extends over 
a period of a fortnight, the scar becoming covered with epithelium and 
showing no tendency to contraction. In protracted cases the healing 
of the ulcers extends over a longer period, and in relapsing cases the 
stage of medullary infiltration may be renewed, and generally it ends in 
resolution. 

From the detachment of the slough occurs the danger of hemorrhage, 
which is usually gradual, though sometimes profuse and immediately 
fatal. In the former case the blood is intimately mixed with intestinal 
contents, or forms a continuous or broken clot ; in the latter the intestinal 
contents are liquid blood. 

Perforation of the wall takes place from the extension of the ulcer in 
depth, and is, as a rule, preceded by the formation of fibrinous adhesions 
between the peritoneum at the base of the ulcer and that contiguous. 
The base of the ulcer, if gangrenous, yields to the pressure of the intes- 
tinal contents or to intestinal peristalsis and is torn through : thus the 
intestinal contents escape into the peritoneal cavity, causing a general 
peritonitis. A localized peritonitis may take place when the sloughing 
ulcer is in the vermiform appendix, or when the peritoneal surface of 
the intestine is firmly attached to adjacent peritoneum. 

The mesenteric lymph-glands, especially those near the lower end of 
the ileum, the ileo-csecal chain, become hyperplastic. They may increase 
to the size of pigeons' eggs, and are soft, and on section of a reddish-gray 
color. Eesolution of the inflamed gland usually takes place, although 
necrosis may occur, with softening and detachment of the overlying peri- 
toneum, resulting in the escape of the necrotic material into the peritoneal 
cavity and a consequent peritonitis. 

The spleen is also hyperplastic, and during the second week may be- 
come tripled in size, except when it is atrophied or its capsule indurated. 
As the spleen enlarges it is at first of a dark-red color, and later becomes 
pale red. The consistency diminishes with the increase in size, and on 
section, especially in the later stages of the disease, the pulp resembles 
dregs of paint, and the follicles and trabecule are indistinct. Hemor- 
rhagic infarction and abscess of the spleen may occur as complications. 
During the later stages of the disease as the spleen diminishes in size the 
capsule becomes flaccid and opaque. 

The heart, liver, and kidneys show the granular degeneration of pro- 
toplasm characteristic of infectious disease. The heart is opaque gray 
and flaccid ; the liver is enlarged, opaque gray, the lobular regions indis- 
tinct. At times both liver and kidneys contain opaque white specks, 
which are either accumulations of round cells or foci of necrotic cells. 



INFECTIOUS DISEASES. 



123 



Ulceration of the larynx, catarrhal bronchitis, and hypostatic lobar 
and lobular pneumonia are frequent. Gross alterations of the brain and 
its membranes are infrequent, although a meningitis at times follows a 
complicating inflammation of the middle ear or acute parotitis. Micro- 
scopical changes affecting the ganglion-cells have been described by sev- 
eral observers. Venous thrombosis, especially of the veins of the leg, is 
of not infrequent occurrence, and sometimes proves a cause of fatal embo- 
lism during convalescence from the fever. Hyaline degeneration of the 
voluntary muscles, especially of the abdominal rectus, was discovered 
by Zenker, and may prove a source of hemorrhage into the muscle, — 
hsematoma, — by favoring its rupture. Orchitis sometimes occurs. 

Symptomatology. — Although typhoid fever may begin abruptly 
with a chill, in most cases its development is so insidious that it is almost 
impossible to fix the day of attack, — weariness, malaise, epistaxis, head- 
ache, slight aching pains in the legs, increasing weakness, and accelerated 
pulse, with perhaps slight diarrhoea, being the only manifest symptoms. 
During this stage there commonly is in the evening a slight elevation 
of the bodily temperature, which as the disease progresses takes upon 
itself the peculiar almost characteristic temperature rhythm of typhoid 
fever. Not rarely there is at first such tendency to remission and 
exacerbation of the symptoms as to suggest the presence of malarial 
disease. As the days go by, the symptoms grow more marked, the pulse 
becomes more frequent and feeble, the fever very distinct ; tympanites, 
often with tenderness and gurgling in the right iliac region, especially 
under pressure with the fingers, appears ; and the habitual hebetude of 
the disease is manifested. If there be not at this time diarrhoea there is 
commonly a peculiar susceptibility to the action of laxative drugs ; but 
constipation may exist. The tongue, at first covered only with a fine 
whitish fur, coats itself more deeply and becomes brownish and often red 
at the tip. About the seventh day the peculiar eruption appears ; it con- 
sists of minute rose- colored spots, resembling very closely flea-bites, dis- 
appearing under pressure and rapidly reappearing when the pressure is 
taken off, and not perceptibly elevated above the surface. The eruption 
in most cases appears first upon the abdomen, but may come out upon 
the chest, the back, or even the limbs. The spots may be found with 
difficulty, are in most cases few in number, widely scattered, and appear 
in successive crops, beginning to fade in one or two days after they de- 
velop. Sometimes peculiar bluish or slate-colored macules precede the 
development of the characteristic eruption, and when there is free per- 
spiration sudamina are usually abundant. In severe cases, during the 
second week of the disease the tinnitus aurium begins to give way to 
hardness of hearing, the simple hebetude to stupor, often with muttering 
delirium ; unless prevented by special care, the tongue becomes dark 
brown, often gashed and red on the edges or tips, whilst sordes collect 
upon the teeth. During the third week, and sometimes into the fourth 



124 



GENERAL DISEASES. 



week, the symptoms steadily increase ; the pulse grows frequent and 
feeble, the temperature reaches its maximum elevation ; subsultus ten- 
dinum, muttering delirium, and carphologia evince the general exhaus- 
tion ; whilst great abdominal distention and diarrhcea, with perhaps 
bloody stools, mark the severity of the local intestinal disease. Usually 
in most cases ending fatally extremely rapid, feeble pulse, coma or coma 
vigil, absolute dryness of the mouth, with an almost colliquative sweating 
of the hot surface, enormous distention of the abdomen, hiccough, irregu- 
larly intense hyperexia, and finally the Hippocratic face, mark the pas- 
sage, by insensible degrees, from life to death. Sometimes, however, the 
course of the disease is more stormy, the delirium becomes furious, and 
the restless motor excitement deepens into violent convulsions, in which 
the patient may die or pass into a fatal coma. 

When the case terminates favorably, the return to health may be 
marked by an abrupt crisis ; usually, however, it is gradual. The tongue 
grows more moist and begins to clean ; hour by hour the nervous symp- 
toms subside ; the pulse lessens in frequency and gains in power ; the 
local abdominal symptoms little by little become less pronounced 5 the 
temperature falls ; and so the patient passes into a condition of great 
weakness without active symptoms, from which he slowly emerges. When 
the tongue as it becomes moist cleans gradually at the tip and edges, 
the convalescence is usually steady ; but when the throwing off of the fur 
begins in the centre or towards the base, and the surface is left smooth, 
red, and shining, the convalescence is apt to be tedious and interrupted 
by various accidents. There is loss of weight during the whole period 
of a typhoid fever, but it is in the early stages of the convalescence that 
the emaciation most plainly shows itself.* 

Especially during the early stages of convalescence, bodily exhaustion, 
mental or emotional excitement, or improper food may produce a sudden 
rise of bodily temperature, constituting what is sometimes spoken of as 
a recrudescence, f The rapid abatement of the symptoms sharply sepa- 
rates the recrudescence from the genuine relapse, in which there is a true 
return of the phenomena of the disease. The tendency to relapse varies 
very greatly in different epidemics of the disease ; by some writers the 
proportion of relapses is placed as low as one per cent., by others as 
high as ten or even fifteen per cent. As the cases are commonly seen in 
this country we do not believe that true relapses occur in more than four 
or five per cent. The most common period of their development is the 

* The description of typhoid fever given in the text is rather as it was formerly- 
seen than as it is witnessed at present in our hospitals ; in other words, it is a descrip- 
tion of the disease as it exists in nature, unmodified by the cold-bath treatment. 

f The terms "recrudescence" and "relapse" are variously used by different 
authors. Recrudescence has been defined to be a relapse without an intervening 
period of normal or nearly normal temperature. Many authorities believe that a 
recrudescence depends upon a reintroduction or a renewed activity of the bacilli. 



INFECTIOUS DISEASES. 



125 



second week of convalescence, though they may come on earlier than 
this, or after many days of freedom from fever. Their development is 
usually abrupt, and the rising temperature, whilst resembling that of 
the first attack of the disease, is more rapid in its elevation. Eruption, 
enlargement of the spleen, and abdominal and nervous symptoms similar 
to those of the primary disease occur in regular sequence, but usually the 
course of the relapse is much shorter, and the changes in the condition 
of the patient are more abrupt, than in the primary attack. The relapse 
may be more or less severe than the primary attack, and may in its 
turn be followed by a second or even a third relapse, so that the entire 
history of the case may spread over the course of many months. 

Headache may be a very early symptom of typhoid fever, and, 
although it sometimes abates as the disease progresses, may continue 
throughout the case. It may be occipital or frontal or without localiza- 
tion. In some cases it is so severe as to constitute the most prominent 
symptom, and it may be associated with vertigo, intolerance of light and 
sound, retraction of the head, tinnitus aurium, and even muscular con- 
tractions in the back and limbs, under which circumstances the case 
closely simulates one of meningitis. 

The typical mental condition of typhoid fever is a peculiar hebetude 
or mental immobility, which is the basis of the so-called " typhoid face," 
whose characteristics are dulness and lack of expression. In some of the 
cases there is during the first eight or ten days a troublesome insomnia, 
but ordinarily a tendency to somnolence predominates from the start, 
and becomes marked after the first week, when it may gradually deepen 
into a stupor with or without muttering delirium. The delirium may 
in severe cases appear as early as the second or third day of the disease, 
but ordinarily it is not pronounced until the patient is well advanced 
into the second week. Cases have been recorded in which the delirious 
excitement came on so early and so completely masked the more ordi- 
nary symptoms of the disease that the diagnosis of acute mania was 
reached and the subject sent to an asylum. It is affirmed by some 
French writers that this primary delirium may closely simulate severe 
melancholia and other forms of acute alienation. Ordinarily the de- 
lirium is first manifested at night, and especially in periods of half-sleep. 
It is usually quiet and muttering, but may become furious, with outcries 
and attempts at violence. It is very apt to vary from day to day in the 
same subject, and in fatal cases may persist until death, though more 
commonly it is replaced by coma. Even in its milder forms it frequently 
leads the patient, especially at night, to rise and wander off in search of 
the ignis-fatuus of his dreams. It is generally associated with high tem- 
perature ; but Liebermeister calls attention to the fact that in some in- 
stances it is concurrent with marked depression of the temperature. In 
most favorable cases it gradually disappears, but it may continue into 
convalescence and pass by insensible degrees into a confusional insanity. 



126 



GEXEEAL DISEASES. 



On the other hand, confusions! insanity may come on during convales- 
cence from typhoid fever after intelligence has been regained. 

It is often difficult to decide how far catarrhal changes and the 
peculiar depression of the nervous centres are the causes of the early 
dulness of hearing, which may deepen into profound deafness, and also 
of the loss of tactile sensitiveness. The taste is almost abolished in grave 
cases, and the vision is dulled. 

In advanced typhoid fever of very severe type continuous rigidity 
and spasmodic contractions of all or a part of the muscles of the trunk 
and of the extremities may develop, and even such local spasms as those 
which produce strabismus or trismus may be pronounced without the 
existence of any meningeal inflammation. Violent epileptiform con- 
vulsions occasionally occur. 

Special Symptoms. — Elevation of temperature is among the earliest 
of the symptoms of typhoid fever. In typical cases during the first week 
there is a peculiar ascent of the temperature which is almost character- 
istic of the disease, — the minimum temperature in the morning and the 
maximum in the evening being from half a degree to a degree and a half 
higher than the corresponding temperature of the day before. As the 
daily swing of temperature is from a degree and a half to two degrees, 
the morning temperature is about half a degree lower than the tempera- 
ture of the evening before. By the eighth or ninth day a morning tem- 
perature of 102.5° to 103° F., with an evening temperature of 104 c to 
105° F., may be reached, and be maintained with more or less steadiness 
until some time in the third week. The first abatement of the fever 
is usually shown in the morning temperature, so that the daily swing 
will be two or even more degrees, and in the fourth week a fall and rise 
of three or even four degrees is not rare. The course of the tempera- 
ture curve of typhoid fever is so modified by modern treatment that a 
typical temperature chart is rarely seen ; and even under the old methods 
great irregularities were often present during the second and third weeks. 
105° F. is a common maximum ; 106° F. is not rare, but is always of very 
serious import ; when 107° F. or over is reached death is usually not 
far off. The time in the twenty-four hours of the highest temperature 
varies : it is generally about five or six in the evening, but may be much 
earlier or later. Rarely there are two temperature maxima in a single 
twenty-four hours, and cases of inversion of the temperature rhythms — 
i.e., with the highest point in the morning — occur, especially in young 
children. The subsidence of fever is ordinarily gradual, but may be 
abrupt, and is commonly accompanied by great irregularities of the 
temperature. 

The pulse in typical typhoid fever is accelerated from the very 
beginning, and throughout the course of the disease preserves a certain 
parallelism with the temperature, being also closely affected by the 
degree of exhaustion and by the various accidents of the disease. Cases 



INFECTIOUS DISEASES. 



127 



have, however, been reported in which an early fall in the pulse-rate has 
persisted through the whole attack, and in some instances the patient 
has passed through the cycle of changes with a normal pulse-rate, not- 
withstanding a distinct elevation of temperature. At first the pulse may 
be full and offer a degree of resistance to the finger, but it soon becomes 
very soft, though large, and early in the disease is apt to take on a 
dicrotic character. In rare cases it may be tricrotic or even polycrotic. 
In bad cases the heart-sounds are altered in the accentuation, or there 
may be disappearance of the first sound whilst the second loses its sharp- 
ness and in rare instances may be duplicated ; the precordial impulse 
also may become so markedly diminished as to be replaced by a simple 
undulation of the chest-wall. 

The respiratory movements are increased in frequency in typhoid 
fever to a degree corresponding with the height of the fever. Early 
in the attack there is often some cough, which may subside or may 
continue throughout the disease. In the advanced stages, especially 
of bad cases, increased rapidity of breathing may often be noticed, and 
be accompanied by lessening of the basal pulmonary resonance and also 
of the respiratory murmur in the posterior portion of the lung, with or 
without the development of a coarse crepitant rale. Under such cir- 
cumstances there is present the so-called hypostatic pneumonia. True 
lobar pneumonia may also be developed at any stage of a typhoid fever, 
and give rise to symptoms which are similar to but less pronounced than 
those of the ordinary disease ; it is to be recognized by the association 
of percussion dulness with bronchial breathing and increased vocal 
resonance. Hemorrhagic infarcts and pulmonary apoplexy, which were 
noted by Hoffmann in five out of two hundred and fifty autopsies on 
persons dead of typhoid fever, should be suspected when haemoptysis 
occurs. 

In most cases of typhoid fever the abdominal symptoms are pro- 
nounced ; loss of appetite occurs early ; and whilst in the majority of 
instances there is not much nausea or vomiting, these symptoms may be 
so continuous and severe as to suggest bilious fever. Diarrhoea is an 
almost universal symptom, but the bowels may not move frequently 
unless there be some laxity in the diet or a loosening medicine be given. 
In rare cases there may be constipation, and autopsies have been reported 
in which scybala were found resting upon the typhoid fever ulcers. The 
characteristic stool of typhoid fever is of a light ochre-yellow color, very 
watery, offensive, alkaline, and, it may be, ammoniacal. It separates 
on standing into an upper serous and albuminous layer and a lower 
flaky sediment. Brownish stools are common in the early stages ; frothy, 
pultaceous, and even purulent stools sometimes occur. Intestinal hemor- 
rhage happens in about five per cent, of the cases ; it is very rare during 
the first week, and when present is probably the result of an oozing from 
the mucous membranes and is of small amount. Serious hemorrhage is 



128 



GKENERAl DISEASES. 



most frequent in the third week : it may give rise to tarry stools or red 
bloody discharges with or without jelly-like clots : it is often recurrent. 
It is always a serious symptom, but our experience in civil life coincides 
with that of Trousseau and of Graves that it is rarely fatal. Statistics 
seem, however, not to be in accord with this, and epidemics have been 
reported in which nearly all the cases died. Liebermeister saw a death- 
rate of twenty-seven per hundred, Murchison fifty-three per hundred, 
and Homolle (four hundred and ninety-eight cases; forty-four per hun- 
dred. When the intestinal hemorrhage accompanies other hemorrhages 
and is the outcome of a general blood dyscrasia. the prognosis is very 
grave. When the bleeding is due sinrply to the ulceration opening one 
or more blood-vessels, the danger is usually in direct proportion to the 
amount of the hemorrhage. According to Murchison. perforation occurs 
much more frequently after hemorrhage than in other cases. A large 
intestinal hemorrhage is accompanied by a sudden drop in the tempera- 
ture (even as much as seven degrees , pallor, free sweating, coldness of 
the surface, faintness, and failure of the circulation. A fatal internal 
hemorrhage may occur without the voiding of blood and cause collapse 
ending in death. The nervous symptoms are often temporarily abated 
by the hemorrhage. 

Perforation of the intestines, according to Murchison, takes place in 
about eleven per cent, of fatal cases. In its typical form it attacks the 
small intestine, and is ordinarily simple, though it may be multiple. In 
rare cases it has been noted in every portion of the large intestine from 
the caecum to the rectum. It is said to be more frequent in males than 
in females, and especially to occur in severe cases in which there has 
been an abundant diarrhoea, but it may suddenly end the scene even in 
walking typhoid. It has been noticed as early as the eighth and as late 
as the hundredth day of the disease, but is especially apt to occur in 
the early part of the third week. Its happening in a typical case is 
marked by a chill, very pronounced fall of temperature followed in a 
short time by hyperpyrexia, nausea, vomiting which may in rare cases 
be faecal, lessening of the alvine discharges, increased meteorism and 
abdominal tenderness, and very anxious face. It may, however, occur 
without any pronounced symptoms, and be entirely masked. When per- 
foration of the large intestine takes place, the general symptoms are 
much less severe than when the small intestine is the seat of the lesion, 
and the resultant peritonitis is often local, ending in an abscess which is 
usually faecal. 

Enlargement of the spleen, beginning from the third to the seventh 
day of the disorder, is almost universal, and. though liable to be masked 
by the tympanites, can usually be detected during life by gentle per- 
cussion and palpation. The smooth, not indurated, slightly tender organ 
may be three times its natural size, and generally begins to diminish at 
the close of the third week. 



INFECTIOUS DISEASES. 



129 



The urine of typhoid fever is usually less than the norm in amount, 
extremely acid, and of high specific gravity. When convalescence 
occurs there is an increase in the urinary discharge which may amount 
to polyuria, with a more than corresponding decline in the specific 
gravity, which sometimes falls to 1003. At the same time the urine 
becomes less acid, in some cases alkaline. During the period of in- 
creasing fever there is a notable increase in the amount of urea elimi- 
nated : Vogel noted the enormous daily output of seventy- eight grammes. 
During the second and third weeks the elimination of urea remains above 
the norm, but falls as convalescence becomes established, even to a point 
much below the norm. The uric acid is always increased during the 
febrile period, and decreases with defervescence. The chlorides, phos- 
phates, sulphates, and carbonates are diminished during the fever, but 
increase with defervescence. According to the researches of Roque and 
Weil, the urine of the typhoid patient is extremely poisonous ; Lepine 
and Guerin affirm that they have discovered in it a poisonous alkaloid. 
Teissier has found that whilst in mild cases of typhoid fever urobilin 
may or may not appear from time to time in the urine, in the severe 
cases it is persistently and abundantly present. In a proportion of cases 
varying according to different observers from twenty to fifty per cent, 
there is albuminuria, which usually appears in the second week, but may 
be developed in the first week, and may delay until the third or even the 
fourth week. It is more apt to occur in severe than in light cases. It 
may be due simply to the fever and the disturbance of circulation, or to 
nephritis. According to Bouchard, albuminuria appearing late in the 
disorder is especially prone to be connected with renal disease. Not 
rarely the presence of renal epithelium, of blood-globules, or of epithelial 
or granular casts renders the diagnosis of nephritis clear ; and violent 
hematuria ending in death has been recorded by Duckworth, Greenhow, 
and others. 

Varieties of the Disease. — The wide variations in the course and 
symptoms of typhoid fever have led to the naming of a number of 
varieties of the disease. 

The gastric or bilious typhoid, representing some of the cases of gas- 
tric fever of the older writers, comprises cases in which the vomiting 
is severe and prolonged. Hemorrhagic typhoid is a very deadly form of 
the disease, especially prone to occur in debilitated subjects suffering 
from scorbutus, alcoholism, etc. There is in it a rapid alteration of the 
blood, with profuse hemorrhage from the nose, mouth, intestines, and 
kidneys, — indeed, from all the mucous membranes, — and the formation 
of abundant ecchymoses, blotches, suggillations, etc. In these cases 
the adynamia is extreme from the beginning ; the fever very high ; 
the pulse very rapid and small ; the heart-action greatly enfeebled ; the 
tongue and the mouth loaded with a brownish deposit ; the breath very 
fetid and even ammoniacal. Death occurs in a great majority of the 

9 



130 



GENERAL DISEASES. 



cases, usually before the tenth day, and has been recorded as early as 
the third day. 

Foudroyant typhoid is a very severe form, ushered in with convul- 
sions and other evidences of intense nervous disturbance. Ataxic typhoid 
is that in which there is from the first profound exhaustion with high 
temperature. 

In so-called pneumo-typhoid fever the first symptoms are complicated 
with, or replaced entirely by, those of pneumonia, so that it may be for 
a time impossible to decide whether the individual is suffering from a 
simple pneumonia with typhoid symptoms or from a typhoid fever com- 
plicated with early pneumonia. Gerhardt, in 1875, recorded an epi- 
demic of this form, which is also said to occur sporadically, especially 
in young children. Typhoid fever commencing with pleurisy is spoken 
of by French writers as pleuro-typhoid fever, and is said to occur some- 
times epidemically. 

In the mildest cases of typhoid fever the symptoms may be so slight 
as to be overlooked, especially when the subject belongs to the poorer 
classes, among whom care of person and early consultation of a physician 
are rare. Slight headache, insomnia, a little diarrhoea, a feeling of mal- 
aise and weakness, may constitute all the symptoms. In this way arises 
the so-called walking typhoid. The latency of these cases is remarkable, 
and the disease may progress without care until a favorable termination 
is reached, or, more usually, until the sudden coming on of severe symp- 
toms, or the occurrence of perhaps a fatal accident, enforces attention. 
We have seen in hospital practice a patient walk into the hospital, 
remain seated for some hours, and die suddenly during the subsequent 
night without a diagnosis having been made, and at the autopsy have 
found acutely ulcerated Peyer's patches with perforation of the intes- 
tines of at least four days' duration. 

Apyretic or afebrile typhoid fever includes a class of cases in which the 
temperature does not reach at any time 100° F., and may remain normal 
or subnormal through the whole course of the affection. This form of 
typhoid fever usually represents the mildest degree of the disease ; but 
epidemics have been described -in which, although the other symptoms 
of typhoid fever have been pronounced, and even death resulted, there 
has been little or no fever. In some of these cases a daily rhythm of 
temperature can be noted, in which the diurnal variation is produced by 
a fall of the morning temperature rather than by a rise of the evening, 
so that the patient may be said to have an inverted fever. 

Abortive typhoid is a condition to which, under the name of typhus 
Iwvissimus, attention has been especially called by Griesinger. The symp- 
toms are those of a typhoid fever compressed into a few days, — perhaps 
three, perhaps ten or twelve. The onset is always abrupt, usually with 
a chill, which may be very intense ; the temperature rises rapidly, and 
has been noted as high as 105° F. on the third day ; splenic enlargement 



INFECTIOUS DISEASES. 



131 



appears at once ; the rose spots may be abundant, and any or all of the 
usual typhoid fever symptoms and accidents, such as diarrhoea, intestinal 
hemorrhage, albuminuria, bronchial catarrh, and hypostatic congestion, 
may appear. The defervescence is usually abrupt, accompanied by exces- 
sive sweat, sometimes by a critical polyuria. During convalescence the 
patient is said to be liable to the same sequelse as after ordinary fever. 
Although the resemblance between this disease and typhoid fever is so 
marked, great hesitancy must be felt in considering the two affections 
the same ; but in a case in which sudden death occurred during conva- 
lescence Laveran found the characteristic lesions of typhoid fever in 
Peyer's patches. 

The effect of age upon the symptoms of typhoid fever is decided, and 
even the anatomical lesions appear to suffer alteration. Thus, in the 
infant the infiltration of the abdominal lymphoid glands is much less than 
in the adult, so that the ulcerations are very slight and perforations 
almost unknown. Indeed, according to Rilliet and Barthez, a large pro- 
portion of Peyer's glands do not ulcerate at all, but recover by resolu- 
tion. The symptoms present in the young child sometimes resemble so 
closely those of a remittent fever that one form of the disease is known 
as infantile remittent, the chief manifestations being gastro- intestinal dis- 
order with a remittent fever. These cases are usually mild in type ; in 
the more severe forms of the disease in children the fever is apt to be 
very high and constant. It is worthy of remark that these high tem- 
peratures are better borne by the child than by the adult. The pulse is 
ordinarily very rapid, rising sometimes to 150 and 180, but is very rarely 
dicrotic. The abdominal symptoms are less marked than in the adult ; 
very commonly the abdomen is flattish, and the diarrhoea is usually 
very mild ; moreover, constipation is not extremely rare, and faecal 
accumulation sometimes takes place. Intestinal hemorrhage is almost 
unknown. The rose- colored eruption is frequently absent, and only 
rarely abundant. The nervous symptoms of the disease are ordinarily 
well marked ; convulsions, strabismus, inequalities of the pupil, irregu- 
larities of the pulse, and coma may give an almost complete picture of 
meningitis. The tendency to the occurrence of focal symptoms is shown 
by the fact that sometimes aphasia occurs. The mortality of the disease 
is distinctly less than in the adult, and in fatal cases death is commonly 
due to pneumonia. 

In the very old, typhoid fever is rare, but extremely dangerous ; the 
onset is usually very 'slow and insidious. The spots are commonly want- 
ing j the splenic tumefaction and other abdominal symptoms are less 
marked than in the young. On the other hand, the adynamia is very 
pronounced, whilst the tendency to pneumonia is extreme. The intes- 
tinal ulceration is often severe, so that perforation is not rare, whilst 
severe hemorrhage is very common. 

Complications and Sequelae. — There can be no doubt that the 



132 



GKENEBAL DISEASES. 



typhoid bacillus may coexist and grow along with various other patho- 
genic germs in the human body, producing mixed forms of disease. 
Thus, although it is rare for a typhoid fever to occur in persons suf- 
fering from tuberculosis, the coexistence of the two diseases in active 
process was proved by Kiener and Yillard by examinations made during 
life and after death. A number of cases have been reported of erysipelas 
developing during typhoid fever. Friedlander, Galliard, and others have 
reported cases, many of them with autopsies, in which typhoid fever and 
cholera coexisted. Murchison states that he has seen eight cases in which 
there was coexistence of typhoid fever and scarlet fever, and has five 
times seen typhus graft itself upon a typhoid. 

Of all these mixed diseases, however, the one which has attracted 
the most attention and is of the most importance is the so-called typlio- 
malarial fever, which has been especially studied in this country by 
Woodward, and in France by Colin. The recognition of the true nature 
of such a fever may be rendered easy by the occurrence in the typhoid 
of a manifest quotidian, tertian, or even quartan paroxysm : but very 
commonly the symptoms are so interwoven and obscure as to render the 
recognition of the two poisons difficult. When typhoid fever occurs in 
a highly malarial district, or in a person suffering from chronic malaria, 
or when the enlargement of the spleen is excessive, the blood should be 
carefully examined for the malarial organism. During the late civil 
war the mortality -rate of cases diagnosed as typho- malarial fever was a 
Little over eight per cent. , but it is probable that a very large proportion 
of the cases represented as instances of typho-malarial fever were in- 
stances of malarial fever with typhoid symptoms, whilst others were pure 
typhoid. Only when the typhoid fever eruption is plainly marked, or 
the ulceration of Peyer's glands revealed at the autopsy, or the bacilli 
of Eberth found in the stools or in the body after death, can the prac- 
titioner be sure that there has been a true typhoid fever infection, and 
absolute proof of double infection would require the detection of both 
malarial and typhoid lesions or organisms. In some cases the typhoid 
and malarial fevers follow closely upon each other, although remaining 
distinct : so that it is possible to have relapses of the typhoid with mala- 
rial attacks between them. 

Not only may typhoid fever be combined with any one of the bacterial 
diseases, but almost any local affection may arise during its course. A 
few scattered cases in literature of hemiplegia, monoplegia, and aphasia, 
arising during the active course of the typhoid, show that the nerve- 
centres may suffer from hemorrhage, thrombi, and other organic affec- 
tions. Abscess of the liver, infarction and abscess of the spleen, paro- 
titis, orchitis, abscess in the muscles and cellular tissues, inflammation of 
the lymphatics, periostitis, osteomyelitis, arthritis, and local gangrenes, 
have all occurred from time to time during a typhoid fever. Much 
more frequent than any of them, however, is nephritis, which may be 



INFECTIOUS DISEASES. 



133 



the cause of death. In its history and in its lesions this nephritis does 
not differ from that of scarlet fever, variola, or other infectious disease. 

Convalescence. — The convalescence of typhoid fever is usually slow 
and protracted, especially after a severe case, and many months are often 
required for the gathering together of the strength, and especially the 
powers of endurance. Not rarely great mental inaptitude and inability to 
study or to do intellectual labor remain after the general strength has in 
great part returned. In our experience, however, the mental powers have 
always been finally recovered. Moreover, it is not rare for a patient in 
the end to gain strength and health beyond what was his previous norm. 
Sequelae are exceptional. The most important are insanity of the confu- 
sional type, paralysis, and acute phlebitis, ordinarily affecting one leg 
and producing a true phlegmasia alba dolens. The paralysis is gen- 
erally not complete, and is commonly attended with wasting of the mus- 
cles, and sometimes with contractures or other evidences of muscular 
irritation. The most frequent form is that of paraplegia, monoplegia 
being, however, not very rare. There is usually some disorder of sensa- 
tion, and there may be complete anaesthesia. The bladder and even the 
rectum may for a time be paralyzed. The nervous lesion varies : in some 
cases it is a peripheral neuritis, while in other instances it is a mye- 
litis. When there is paralysis of the bladder or rectum, with paraplegia 
and trophic disturbances in the legs, the lesion is probably always spinal, 
and the prognosis is more grave than in a peripheral monoplegia. The 
paralysis may develop suddenly ; but usually its onset and its subsi- 
dence are alike gradual. The prognosis is much more favorable than in 
similar paralyses due to other causes than infection. 

As has already been stated, periostitis or osteomyelitis may come on 
during a typhoid fever. More frequently the bone lesion manifests itself 
during convalescence, the first symptom being heavy, aching, localized 
pain, with slight swelling and some soreness. This may be followed by 
resolution, or, more commonly, after a remission which may last from six 
to eight months, by a return of the symptoms and a very slowly devel- 
oped necrosis. As was first determined by Ebermaier, these bone lesions 
depend upon the local deposit of the typhoid bacillus. It has farther 
been shown by Dmochowski and Janowski that the typhoid bacillus may 
be deposited in any tissue and produce suppuration, so that under certain 
circumstances it is a pyogenic organism. The typhoid bacillus has been 
found in the brain membranes in purulent meningitis after typhoid, and 
it is probable that milk-leg, neuritis, and other local lesions occurring 
during or after a typhoid fever are directly due to local deposits of the 
bacillus. 

Diagnosis. — For the purposes of treatment it is essential that typhoid 
fever should be suspected at a time when the lack of development of the 
symptoms may make a positive diagnosis impossible. Whenever in a 
youngish or middle-aged person there is an acute and increasing malaise 



134 



GENERAL DISEASES. 



and weakness, without apparent canse. with an elevation of temperature 
in the evening, typhoid fever should be suspected. If at such a time it 
be found that getting the patient suddenly from bed into a standing posi- 
tion notably increases the pulse-rate, the case should be treated as one of 
incipient typhoid fever. The occurrence of epistaxLs. diarrhoea, or other 
of the peculiar symptoms or of the regular ascending febrile movements 
of typhoid fever makes the diagnosis highly probable, although it can 
very rarely be positive until the appearance of the eruption. 

There can be no difficulty in the diagnosis of veil- developed typhoid 
fever, the characteristic synrptoins being the progressive, ascending fever, 
with increasing weakness, nervous disturbance, diarrhoea, enlargement 
of the spleen, and the eruption. In aberrant cases of the disease, how- 
ever, especially in those which resemble meningitis, it may be necessary 
to reserve the diagnosis until the rose- colored spots can be found or until 
time has made the matter clear. The typhoid symptoms are. however, in 
such cases usually so strongly xuonouneed as to give an inkling of the true 
nature of the disease. \Vhen imeunionia develops in the beginning of a 
typhoid fever it may not be possible to determine at once whether the 
case is one of pneirnionia with typhoid symptoms or of typhoid fever with 
pneumonia. Here again a guarded opinion must be given until the ap- 
pearance of the rose spots. Acute tuberculosis sometimes very closely 
resembles typhoid fever, and may offer any symptom of the disease 
except the eruption : indeed, even this may be simulated, except in its 
recurrence in successive crops. A peculiar shifting character of the local 
symptoms in 'any obscure case is suggestive of tubercular disease : thus, 
if to-day the manifestations point towards meningitis, to-morrow towards 
pulmonary involvement, whilst the next day the abdominal synrptoins 
are most x>ronounced. or if rapidly shifting inilnionic congestion come 
and go. tubercular disease should be strongly suspected. A regular 
typhoid fever ascent of temperature tells strongly in favor of a diagnosis 
of typhoid fever, but. unfortunately, irregularities of fever are no proof 
that the case is not one of aberrant typhoid. 

Erhlich's test — the diazo -reaction — is of limited value in the recog- 
nition of typhoid fever. It is true that it is usually responded to after 
the first week of the disease, but it certainly is also responded to in tuber- 
cular disease, including acute tuberculosis, in septicaemia, in measles, in 
pneumonia, and probably in various other febrile diseases. When after 
a week or ten days of obscure symptoms there is still difnculty in differ- 
entiation between gastritis or malaria and typhoid fever, it may be of 
service. For the test a one per cent, solution of sodium nitrite and a 
half per cent, solution of muriatic acid saturated with sulphanilic acid 
are kept separate, but mixed in the proportion of forty to one just before 
using : after mixture nitrous acid is liberated by the action of the hydro- 
chloric acid upon the sodium nitrite, and produces with the sulphanilic 
acid diazo-benzene-sulphonic acid. In making the test, equal parts of 



INFECTIOUS DISEASES. 



135 



the mixture of the two solutions and of urine are thoroughly shaken 
together, and ammonia is poured upon the top. At the line of junction 
a ring forms, which in normal urine is not reddish, but in typhoid fever 
urine is of a color varying from carmine to a deep garnet. 

The presence or absence of the typhoid bacillus in the stools of a 
suspected typhoid case is of diagnostic import. According to Eisner, 
the typhoid bacillus is readily differentiated by making cultures of the 
typhoid stools on potato gelatin impregnated with one per cent, of potas- 
sium iodide. The latter agent is stated to kill all the organisms of the 
fseces except the typhoid and the colon bacillus. At the end of twenty- 
four hours the colonies of the colon bacillus are very distinct as largish, 
brown, coarsely granular spots, whilst those of the typhoid bacillus are 
evident only after forty-eight hours as transparent, small, colorless, finely 
granular spots. 

Prognosis. — The mortality of typhoid fever varies very greatly in 
different epidemics and in different classes of individuals, and has re- 
cently been distinctly modified by improvements in methods of treatment. 
The statistics of the Paris Hospital from 1888 to 1894, inclusive, give an 
average mortality in nearly nine thousand cases of twenty and six-tenths 
per cent., whilst from 1866 to 1881 the mortality was twenty-one and five- 
tenths per cent. In the General Hospital of Vienna, from 1846 to 1861, 
the mortality was about twenty-three per cent. In the French army, 
from 1875 to 1891, about one hundred and thirty thousand cases of typhoid 
yielded an average of twelve and five-tenths per cent, of deaths, the mor- 
tality-rate varying from eleven per cent, in some years to fifteen per cent, 
in others. The same statistics show plainly the difference in the typhoid 
fever in different localities, the rate varying in the one hundred and 
sixty-two large garrisons of France from four and six-tenths to twenty- 
three and seven-tenths per cent. It seems fair to suppose that this 
great difference was the result not of differences of treatment, but of the 
original character of the disease. 

In the Pennsylvania Hospital, out of six hundred and twenty-one 
cases, from 1862 to 1881, nineteen and five-tenths per cent, died, so that 
the mortality in this country is probably not far from what it is in Europe. 
In all these hospital reports are, however, included many cases which 
have come under medical care only at an advanced stage of disease, and 
some when moribund, so that in private practice upon the well-to-do 
classes the older mortality- rate was probably from ten to twelve per cent. 
The use of the cold bath has very sensibly reduced the average mortality- 
rate of the fever, some institutions reporting as low a rate as five or six 
per cent. In applying the general mortality-rate to the individual case 
it must be remembered that the danger of deatli is greatly increased by 
previous disease, old age, or obesity, and also by any neglect of early rec- 
ognition and treatment of the disease. The more severe the symptoms 
in the first week the greater the danger. High temperature is always 



136 



GENERAL DISEASES. 



an unfavorable omen, especially high temperature which is persistent, 
has a high morning register, and cannot be controlled, except with the 
greatest difficulty by means of the cold bath. The early development 
of muttering delirium, especially with tremor and other evidences of 
marked adynamia, is a bad indication. Coma vigil or general con- 
vulsions are sometimes spoken of as fatal symptoms, but we have seen 
recovery from each. A very unfavorable symptom is the belief on the 
part of the patient that he is not sick, or that he is away from home 
and should go there. Eigidity of the limbs, with symptoms of menin- 
gitis, is a serious but not necessarily fatal condition. Great rapidity of 
the pulse, especially when combined with irregularity, is very ominous ; 
in Liebermeister's statistics seventy per cent, of the cases in which the 
pulse was over 120 ended fatally. Slipping down in bed, marking as it 
does an extreme adynamia, great coldness of the surface and the ex- 
tremities, and general cyanosis, often indicate the approach of death. 
Persistent dryness of the tongue with excess of sordes and excessive 
tympanites are much less serious than the symptoms just spoken of, but 
require a guarded prognosis. 

Any of the accidents or complications of the disease add greatly to 
the gravity of the situation. Perforation usually ends in death ; and 
peritonitis without perforation is only a little less fatal. (See also p. 
128.) The significance of intestinal hemorrhage has already been spoken 
of. (See page 128.) Albuminuria indicates simply that the case is a 
grave one, but when persistently associated with tube-casts or other 
evidences of nephritis renders the prognosis doubtful. Hypostatic con- 
gestion of the lungs is serious, but is probably recovered from in the 
majority of cases ; true consolidation of the lungs, occurring in typhoid 
fever, very commonly ends in death. 

It must, however, be remembered that so long as there is life in a 
typhoid fever so long is recovery possible, and that therefore an abso- 
lutely hopeless prognosis is very rarely justified. We have seen recov- 
eries after prolonged coma vigil, pulselessness, absolute inability to retain 
anything on the stomach, subnormal temperature, and a seemingly hope- 
lessly moribund condition. On the other hand, sudden death some- 
times occurs in typhoid fever without distinct warning ; and any acci- 
dent may in a moment entirely alter the aspect of the case. For this 
reason the prognosis should always be guarded. Pulmonary embolism 
from venous thrombosis, and cardiac failure, are the usual causes of 
sudden death, a termination which in our experience has especially oc- 
curred in cases with atheromatous arteries or " athletic heart, ?? either 
of which conditions adds greatly to the danger of a typhoid fever. 

The mortality of typhoid fever is greater in women than in men, and 
the existence of pregnancy notably increases the danger. Out of three 
hundred and twenty-four cases collected by Sacquin abortion occurred 
in two hundred and five, — that is, in sixty-four per cent. It takes place 



INFECTIOUS DISEASES. 



137 



usually from the seventh to the fourteenth day, but may happen very 
early or be delayed even to convalescence. The foetus is usually but not 
always dead before expulsion, and in a large proportion of cases probably 
both the death of the foetus and the abortion are the result of the passage 
of the typhoid bacillus from the mother into the child. The mortality 
of typhoid fever with abortion is about fifty per cent. 

Owing to the insidiousness of the invasion and the gradual defer- 
vescence of typhoid fever, it is usually impossible to fix the first and the 
last day of the disease. Moreover, there is no sufficient reason for be- 
lieving that the time required for the working out of the fever process 
is the same in all cases. In its typical form typhoid fever may be con- 
sidered to have a duration of from three to four weeks, but, as has already 
been shown, there are cases in which convalescence occurs at an early 
period, and according to our experience cases also occur in which the 
fever continues for five or six weeks without its being possible to detect 
any reinfection from outside of the body or any sufficient complication 
to account for the continuance of the fever. The most fixed point is the 
day of the appearance of the eruption, the seventh to the ninth day. 

Prophylaxis. — As in the vast majority of cases the typhoid bacillus 
finds access to the patient in the drinking-water, whenever there is an 
epidemic of the disease in a city, water which has been boiled for some 
minutes or which has been bottled from some distant spring should alone 
be used. The fact that the average yearly number of cases of typhoid 
fever admitted into the hospital in Munich was abruptly and permanently 
changed from five hundred and ninety-four to one hundred, and the 
annual number of deaths in the city from two hundred and eight to 
forty, by a reform in the drainage and water-supply, shows the immense 
importance of sanitary precaution. 

The dejections should always be received into a bedpan which has 
previously had placed in it either one- quarter pound of chlorinated lime 
or half a pint to a pint of a ten per cent, solution of carbolic acid. 
When it is possible, the pan should be emptied into a receptacle con- 
taining a large amount of chlorinated lime, so that it shall be impossible 
for the bacillus to escape destruction ; if an ordinary cesspool or water- 
closet is used, the bedpan after use should be allowed to stand for at 
least half an hour before being emptied, so as to insure the killing of all 
germs. After emptying, the bedpan should be thoroughly washed with 
a solution of five to ten per cent, of carbolic acid and have put in it the 
new charge of germicide. There is probably little choice between chlori- 
nated lime and carbolic acid, except that the chlorinated lime is less apt 
to produce accidental poisoning. Care is, however, necessary to see that 
the chlorinated lime is of good quality and is used with sufficient freedom. 

The bed- and body-linen of the patient should be changed frequently, 
perhaps daily, and immediately whenever they are soiled. So soon as 
they have been taken off they should be tied tightly up in a clean sheet 



138 



GENERAL DISEASES. 



and be put without opening into a boiler, where they should be boiled for 
not less than half an hour before opening. If circumstances require 
that the linen should be washed away from the house in which the sick 
person is, the bundle should be thrown immediately after tying it up 
into a five per cent, solution of carbolic acid and allowed to soak for at 
least six hours before rinsing. In case of death, a ten per cent, solution 
of carbolic acid should be immediately injected into the rectum, and the 
corpse should be wrapped in a sheet wet with a three per cent, solution 
of carbolic acid. 

When practicable, it is certainly preferable to protect the mattress 
and pillows by close-fitting rubber covers. If the mattress be fouled by 
the discharges, it should be soaked in carbolic acid solution and then 
taken to pieces. Under no circumstances should proprietary disinfec- 
tants be used : they are all more or less uncertain in action and greatly 
excessive in price. 

Treatment. — The hygienic and general management of a case of 
typhoid fever has probably much more to do with the result obtained 
than has the medication. The trained nurse is so essential that no skill 
on the part of the physician will atone for her absence. So soon as there 
is the slightest reason for suspecting that a person is getting typhoid 
fever, absolute rest in bed, with the use of the urinal and bedpan, should 
be insisted upon. No harm will have been done if the suspicions be not 
confirmed, whilst incalculable harm may result from unnecessary loss of 
strength during the first few days of the attack. The bed upon which 
the patient rests should be neither too high nor too low, nor yet too 
wide for practical nursing ; at the same time it should be wide enough 
for the comfort of a restless subject. It should always be a mattress, 
not too hard, preferably one upon springs. The room should be as well 
ventilated, and in summer as cool, as possible. 

The question of food is most important, and should be carefully 
supervised in its details by the attending physician. The food should 
be chiefly liquid, but very early in the attack and during the beginning 
of convalescence semi-fluid food may often be allowed with advantage, 
provided it be given in not too large quantities. Thoroughly cooked fari- 
naceous foods, custards, junket, very soft boiled, shirred, or raw eggs, and 
fine hashes, may be mentioned as fulfilling the indications. The feeding 
should always be at short intervals : semi-solid food should be given in 
small quantity at meal-time, purely liquid food being taken with such 
freedom between meals that the patient will want but little. Through- 
out the disease the chief reliance is milk, which ordinarily should be 
diluted with from ten to fifteen per cent, of lime water. When the 
digestion is extremely feeble, further dilution may be required : as a 
diluent barley water is distinctly preferable to ordinary water. Par- 
tially peptonized milk, when taken without repugnance, is advanta- 
geous. The substitution of koumiss, matzoon, or even buttermilk, for 



INFECTIOUS DISEASES. 



139 



a portion of the milk, sometimes affords variety. Often when milk is 
repugnant to the patient's palate the addition of a little salt will cause 
it to be relished. Baw eggs given in sherry or with milk in the form 
of eggnog are often very well borne and very nutritious. The various 
animal broths may be used as adjuvants to milk, but are not to be relied 
upon as affording much nutrition ; beef essence should be considered as 
stimulating rather than nourishing. All meat-essences or broths should 
be made fresh ; u peptonoids,' ' Liebig extracts, and every other form of 
artificial meat-essences or extracts should not be allowed in the sick- 
room. In some cases peptonized oysters afford an innocent and highly 
nutritious liquid food, of which, however, the patient soon tires. 

In all cases a record should be kept of food and medicines as adminis- 
tered during the twenty-four hours, so that the attending physician may 
know exactly what has been taken. During the day food should be 
given at intervals of two hours. In regard to the night, there is danger 
on the one hand of breaking the sleep of the patient, and on the other 
of exhaustion from want of food. If the patient be in a semi-stupor and 
fall asleep directly after being disturbed, the night intervals may be 
short 5 but if there be a tendency to insomnia and nervous restlessness, 
they should be long : the skill of the physician finds exercise in bal- 
ancing between the difficulties. Very rarely is it proper to allow a 
typhoid fever patient to go more than four hours without food. The 
physician in charge should always make a written schedule for the 
twenty-four hours of the times of feeding, administration of medicine, 
etc. 5 and if this be so arranged that food is given at ten p.m., two a.m., 
and six a.m., there will be little disturbance of the patient. When the 
food and stimulants are given at these long intervals they should be in 
larger amounts j and if the exhaustion be severe, the intervals should 
never be longer than three hours. 

It is impossible to lay down with any accuracy the amount of food ; 
the object is to get as much digested as possible, and to put none in the 
alimentary canal which cannot be digested. Most patients will take two 
quarts of milk or milk- food, such as koumiss, with four eggs, in the 
twenty-four hours ; some require much more, some less. Sick stomach, 
excessive tympanites, excessive diarrhoea, and above all the appearance 
of curds or other particles of undigested food in the stools, indicate that 
the patient is taking more food than can be digested. Under these cir- 
cumstances peptonized foods are especially valuable, and it may become 
necessary temporarily to withdraw milk altogether, sustaining the patient 
with animal broths. Strong beef tea with an egg stirred into it whilst 
very hot may be advantageous. In some cases milk diluted with, car- 
bonic acid water is most grateful ; and we have seen a mixture of milk 
and champagne taken by a stomach which would retain no other food. 
Coffee, tea, and even cocoa are rarely in themselves harmful, and may 
sometimes be used with great advantage for the purpose of getting a 



140 



GEXEEAL DISEASES. 



patient to take milk otherwise repulsive to the palate. Cold water 
may be given freely, bnt if the patient be taking already three quarts 
a day of liquid food there will be danger of upsetting the stomach with 
an excess of fluid, so that cracked ice is often preferable. In most cases 
the various liquid foods given cold will be more grateful to a patient : 
rarely the stomach does not tolerate them at low temperature. 

Alcohol in some form, according to our belief, should be used in every 
case of typhoid fever from the beginning, unless there be some very 
strong moral reason for refusing it. as when there is a distinct heredity 
towards drunkenness. Given properly it is incapable of harm. There 
are two distinct uses of alcohol in typhoid and other adynamic diseases. 
Early in the attack, given in small amount with the food, it acts as a 
local stimulant to the digestive organs, and enables the patient to take 
more than would be otherwise possible ; whilst in the advanced stages of 
the disease it is useful as a general stimulant, and should be given freely 
with the food and also at other times. In the first week of an ordinary 
case of typhoid fever a dessertspoonful of whiskey in a tumblerful of 
milk is a full dose, one ounce to two ounces of whiskey being given in 
the twenty-four 1 hours : in the advanced stages of the disease twelve or 
even fourteen ounces of whiskey a day are sometimes necessary. Beyond 
this it does not seem to us it is wise to go. In deciding the amount 
of spirit to be given, the physician must be especially guided by its 
effects as well as by the degree of existing exhaustion : so long as the 
pulse under the use of the spirit becomes slower and steadier, and the 
tongue more moist, and the nervous symptoms less severe, so long is it 
probably doing good. Whenever the patient flushes or becomes ner- 
vously excited after the single dose, or whenever the odor of the liquor 
appears on the breath, or the pulse takes on the peculiar angry feel 
which every experienced practitioner must know, too much of the spirit 
is being taken. It should always be given at short intervals, in sinall 
quantities, usually every two hours during the day and every three or 
four hours during the night, the individual night portion being larger 
than the day allowance. 

The most important part of the treatment of typhoid fever is that 
which has to do with the reduction of the temperature. Antipyrin. 
phenacetin, guaiacol, and similar antipyretic drags will, if given in suf- 
ficient dose, certainly act efficiently in typhoid fever, but they may 
cause collapse. Moreover, they are powerful disturbers of the nutritive 
processes of the body, and the method of their action upon nutrition 
when altered by fever still remains a matter of pure conjecture. It 
seems to us established by experience that they are capable of doing 
great harm in typhoid fever, and that their most careful administration 
in antipyretic doses is not only more dangerous but much less bene- 
ficial than the external application of cold. If used at all. they should 
be employed in small doses, simply for the purpose of hindering the 



INFECTIOUS DISEASES. 



141 



rise of temperature in those cases in which the baths would otherwise 
have to be given at too short intervals. 

Whilst it is not true that the external use of cold will always prevent 
death in typhoid fever, it does seem to be true that, when used from the 
beginning with other judicious measures, it will reduce the mortality-rate 
to three or four per cent. So soon as a patient reaches the temperature 
of 102° F. he should be freely sponged with cold water, the person being 
freely exposed to the air whilst the process is being carried on. If the 
temperature rises to 102.5° F., more efficient hydrotherapeutic measures 
should be instituted. The least disturbing and the least efficient of these 
is the cold pack. The naked body of the patient, lying upon a rubber 
blanket above the sheet of the bed, is to be wrapped in a sheet wrung 
out of ice-water ? and pieces of ice so placed that their outflow shall 
spread over the sheet and keep it cold. If a fever patient in a cold pack 
be wrapped in a blanket, the pack becomes a hot one. The cold pack in 
adults suffering from typhoid fever so generally fails to reduce the tem- 
perature sufficiently that it is scarcely worth while to try it ; in children 
it frequently suffices. 

Next after it in power is the bath at 80° F., cooled, if necessary, 
whilst the patient remains in it. Finally, there is the cold bath of 
70° F., which will reduce any temperature rapidly. In using the bath 
the patient must be lifted from the bed with every precaution to pre- 
vent movement on his part. The bath should be repeated every two, 
four, six, eight, or ten hours, according to the necessities of the indi- 
vidual case, the bodily temperature never being allowed to remain above 
102.5° F. The temperature of the patient sometimes continues to fall 
for some minutes after removal from the bath, so that it is usually ad- 
visable to take the temperature of the patient in the bath, by the mouth, 
or, better, the rectum, and to remove the patient when the bodily heat 
falls to 100° F. 

It is essential that hospitals be provided with a movable bath-tub 
which may be taken directly to the bedside of the patient. In private 
practice portable tin or rubber bath-tubs are sometimes available. When 
the cold bath is used the sensations of the patient are commonly very 
unpleasant ; there may be much shivering and excessive complaint of 
cold. Considerable relief is sometimes afforded by freely rubbing the 
extremities whilst the patient is in the bath, and in many cases the 
putting of a hot- water bag to the feet whilst in the bath will give great 
comfort, and do good by preventing the blood from being altogether 
driven to the trunk. 

The effects of the external use of cold are so decisive that in private 
practice the practitioner should insist that every obstacle be surmounted. 
An easy method of using cold is that devised by H. C. Wood. An ordi- 
nary cot should be placed at the side of the bed, half opened, and covered 
with a rubber sheet so arranged that the upper end goes over the head- 



112 



GENERAL DISEASES. 



board, whilst the lower end forms a sort of trough at the foot of the cot. 
the head of which is slightly elevated. The rjatient. being wrapped in a 
sheet, can be readily slid from the bed into the cot. and then by means of 
a large carriage-sponge soused continuously with cold water, which lies 
also about the patient and as it accumulates runs off at the bottom of the 
cot into a tub. E. H. Fitz places the rubber sheet under the patient in 
the bed. makes a trough of it. and souses with water as required. 

Under proper management, instituted early, contra-indications to the 
use of the cold bath are very rare. Menstruation is not a contra-indi- 
cation. Pulmonic congestions and pneumonia are largely prevented, 
and. when they occur, do not forbid the use of cold if the bodily tem- 
perature be 103 c F. Intestinal hemorrhage and peritonitis are. on the 
other hand, contra-indications to the use of the bath, as is also extreme 
exhaustion with feeble heart, such as is seen in persons who have suf- 
fered from long-continued high temperature in typhoid : when it is 
necessary to reduce the temperature in a person ^rith very feeble heart, 
the latter should be sustained with strophanthus and digitalis, the bath 
should not be below 80° F.. and the extremities should be kept warm as 
far as possible by hot applications while the subject is in the bath. 

Treatment of Symptoms and Accidents. — The medicinal treatment of 
typhoid fever consists chiefly in meeting indications for the relief of 
symptoms which may arise from time to time. When in the first days 
of the attack there is any tendency to excessive furriness of the tongue, 
nausea, vomiting, or constipation, good results often may be obtained by 
the cautious administration of calomel I from one-eighth to one-twelfth of 
a grain) every two to three hours until griping pains or liquid passages 
are produced. Constipation in the course of the disease is to be met by 
enemata. 

TThen there is persistent nausea or vomiting in typhoid fever the diet 
should consist exclusively of two to three parts of milk with one part of 
lime water, or of milk and carbonic acid water, and. if these fail, of animal 
broths. In very severe cases no stronger food than wine whey, barley 
water, or albuminous water strain white of eggs through muslin and mix 
with double the amount of water) may be borne, and sometimes it may 
even be necessary to withdraw for a time all food by the mouth, the 
patient being sustained by thoroughly peptonized nutrient injections. 
The drugs which are useful are cocaine (from one-eighth to one-quarter 
of a grain) ten to twenty minutes before the administration of food : bis- 
muth, with or without minute quantities of calomel according to the in- 
dividual case, administered when the stomach is empty : and nitrate of 
silver (one-eighth of a grain) A sinapism or a blister to the pit of the 
stomach may be of great service. 

Unless the diarrhoea amounts to more than three passages a day. it 
should be rarely interfered with. If the patient fail to have a loose stool 
every day, especially if there be a tendency to excessive tympanites. 



INFECTIOUS DISEASES. 



143 



sweet oil may be given, or a small injection may be used. For the con- 
trol of excessive diarrhoea, paregoric, or opium suppositories, may be 
employed. The mixture of bismuth and carbolic acid (see formula 5) 
is especially valuable. Barely vegetable astringents may be used, such 
as the logwood mixture. (See formula 6.) When the stools are large 
and very thin, plumbic acetate may be given. Beta-naphtol, with small 
doses (three grains) of strontium salicylate, sometimes acts favorably. 

There is some difference of opinion in the profession as to how far the 
intestinal ulceration can be affected by remedies. Pepper believes that 
silver nitrate is useful in this way : it should always be given in pill, 
with a little extract of opium. The practice originally introduced by 
George B. Wood of using oil of turpentine in typhoid fever still meets 
with much favor, and we believe is capable of doing great good. Modern 
research has shown that oil of turpentine is especially inimical to the 
typhoid fever bacillus ; and, owing to its volatility, it must when freely 
given fill the whole intestinal tract with its vapor, and influence not only 
the bacillus but also the process of ulceration. When properly adminis- 
tered the drug is harmless to the patient, and I (EL C. W.) believe it should 
be given as a matter of routine to every case, unless for some reasons es- 
pecially contra-indicated, from the middle of the second week until to- 
wards the close of the fever, either in capsule or in emulsion, five or ten 
minims from three to six times in the twenty-four hours. If it disturb 
the stomach it should be withdrawn. Sometimes during convalescence 
Peyer's patches are very slow to heal, and keep up a tendency to diarrhoea. 
Under these circumstances I (H. C. W.) have repeatedly seen the best 
results obtained by the use of turpentine after the failure of other means. 
Thymol is strongly recommended by some clinicians in doses of from two 
to five grains as a substitute for turpentine. Carbolic acid, salol, iodine, 
and chlorine have all been strongly recommended for the purpose of de- 
stroying the typhoid bacillus, but there is no sufficient reason for be- 
lieving that the course of typhoid fever can be modified by any of these 
agents. Some of them may act favorably by their local effect upon the 
alimentary canal. In choosing a remedy the practitioner should always 
see that the drug selected is incapable of harm. The treatment of typhoid 
fever at one time in vogue by large doses of hydrochloric or other mineral 
acid certainly accomplishes nothing so far as the general disease is con- 
cerned, and very frequently increases the local irritation. 

In all cases of typhoid fever with severe abdominal symptoms and 
tympany, counter-irritation over the whole surface of the abdomen by 
means of the spice plaster, or the turpentine stupe, or a cloth wrung out 
of a tincture of spices, should be practised. The application of the tur- 
pentine stupe followed by warm fomentation is perhaps the best method. 

When intestinal hemorrhage occurs, opium should be freely used 
to secure quiet and prevent alarm ; absolute rest must be enjoined, and 
in severe cases the patient should not be disturbed with the bedpan, but 



144 



GENERAL DISEASES. 



allowed to pass the dejecta into a sheet. Ice should be applied over the 
surface of the abdomen, and the food should be restricted with a severity 
proportionate to the severity of the hemorrhage. In bad cases albumin 
water or strong animal broths or essences should alone be given. Styp- 
tics are of value if properly employed, but the greatest care should be 
exercised not to upset the stomach or irritate the intestines with them. 
According to our own experience, the best styptic is Monger's salt (not 
solution), which should be given in double caj^sule in doses of one-half to 
one grain, at intervals of from one to four hours. Tannic acid is used 
by some practitioners, whilst others employ plumbic acetate. Oil of 
turpentine has some haemostatic power, and. if the patient have not taken 
it already, may be used. Oil of erigeron in doses of fifteen to twenty 
drops every two or three hours may sometimes be advantageously substi- 
tuted. Extract of ergot (ten grains in capsules) may be of great service : 
we often alternate it with Monsel's salt in such a way that the patient 
gets one or the other every two or three hours. In sudden bad cases 
extract of ergot may be given hypodernneally. 

Collapse occurring from intestinal hemorrhage must be met with the 
usual remedies, and transfusion would seem to be indicated in some cases : 
or the normal saline solution (one-half per cent.) may be injected into the 
reins or the buttock. (See Cholera.) 

Peritonitis in typhoid fever is usually dependent upon perforation, 
and ends fatally when not localized in the neighborhood of the appendix. 
Its best treatment is in the use of opium up to continuous mild nar- 
cotism and in abstinence from food. When perforation can be diag- 
nosed with fair degree of certainty the question of the performance of 
laparotomy becomes a very urgent one. Undoubtedly perforation is 
occasionally recovered from without surgical interference : how often, 
it is impossible to say accurately, because the diagnosis of perforation 
can rarely be made with absolute certainty before death. Recovery 
from peritonitis certainly occurs, as Fitz in 1S91 collected twenty-seven 
recorded cases. — three after operation, seventeen after resolution, and 
nine after the spontaneous discharge of pus. He farther examined the 
records of ten cases of early operation for perforation with one recovery. 
According to Osier, the corrected statistics up to 1S95. excluding doubt- 
ful cases, are seventeen cases with three recoveries, or. taking all the 
cases, twenty-four laparotomies with six recoveries. 

TThen headache in typhoid fever is severe enough to require treat- 
ment, phenacetin or antipyiin may be used very carefully and only in 
moderate dose : under no circumstances should they be actively pushed, 
the reliance being upon opium if the pain be otherwise uncontrollable. 
Ice to the head is often of service ; blistering over the back of the neck 
or to the scalp is to be employed only with the greatest reluctance, 
especially when there is severe adynamia, since there is always danger 
of sloughing or other severe local symptom. Nevertheless, when epilep- 



INFECTIOUS DISEASES. 



145 



tiforni convulsions occur, or when the delirium and insomnia are exces- 
sive, a blister may be applied to the scalp ; it should not be allowed to 
remain on more than half to three-quarters of the ordinary period, the 
part being dressed with a poultice if the blister has failed to rise. For 
the relief of insomnia, opium, trional, or sulphonal may be employed. 
When there is no pronounced exhaustion, chloral may act most happily, 
but it must always be given with great caution ; ordinarily the best 
results are obtained by a combination of the narcotics. 

In the excessive adynamia of typhoid fever strychnine (one-thirtieth 
to one-fifteenth of a grain) is a most useful remedy. In severe cases it 
should be given hypodermically at intervals of four hours, or, better, 
alternately with cocaine (one-sixth to one-third of a grain) at intervals 
of six hours (three hours between doses). Digitalis and strophanthus 
are sometimes useful for sustaining the heart. 

In the crisis of typhoid fever, when the failure of vital power shows 
itself in simple collapse, in a furious delirium, in a high temperature 
which cannot be controlled except for the moment by the application of 
cold, or in coma vigil, musk is a very valuable remedy. It should be 
given in doses of fifteen grains every four to six hours by the rectum in 
two ounces of starch water, with a little laudanum. 

Pulmonic congestion in typhoid fever calls for further stimulation of 
the circulation, as it is largely the outcome of cardiac and vaso-motor 
weakness : alcohol, strychnine, cocaine, and digitalis should be given, 
alternately or in combination. Large doses of extract of ergot (ten grains 
every two or three hours) may be used for vaso-motor stimulation, whilst 
oil of turpentine or of eucalyptus and terebene are the best expectorants. 
Turpentine stupes should be used freely. Ammonium carbonate is given 
by various practitioners, but its employment in large amounts continu- 
ously is of doubtful expediency in a low fever with blood dyscrasia. 

TYPHUS FEVER. 

Definition. — An acute, contagious, febrile disease, without pathogno- 
monic lesions, characterized by an abrupt onset, great prostration, high 
fever, profound nervous disturbances, and a macular eruption which usu- 
ally appears from the third to the fifth day and often becomes petechial. 

Etiology. — Typhus fever is, in all probability, dependent for its 
existence on some peculiar organism, although such organism has not as 
yet been isolated. It is endemic in Ireland, Bohemia, the Valley of the 
Danube, and certain other portions of Europe, and is liable to occur epi- 
demically in any portion of the world. It has been closely connected with 
famine, overcrowding, and the miseries of extreme poverty ; and it lias 
especially abounded in jails, in emigrant ships, and during sieges, — hence 
the names of prison fever, ship fever, camp fever. It is extremely con- 
tagious, the danger increasing enormously when cases are collected in 
hospitals, under which circumstances the nurses and medical attendants 

10 



146 



GENERAL DISEASES. 



are very prone to suffer. It may be communicated through the wearing 
apparel, the bedclothing, etc., and persons not suffering from it them- 
selves may "become sources of infection. Epidemics may also arise from 
bales of rags or other similar material which have been gathered in 
affected districts. It is probable that the poison escapes from the body 
through all possible avenues, although on this point there is little defi- 
nite knowledge. 

Epidemics are more common and more severe in winter than in sum- 
mer, probably because of the herding together of people and the lack of 
ventilation which prevail in cold weather. It is therefore a matter of 
the gravest importance to provide in every fever hospital wards where 
patients may be isolated and abundantly supplied with fresh air, whilst 
the utmost precaution should be taken in the disinfecting of the dis- 
charges, of the bed-linen, and of the clothing. (See Typhoid Fever.) 

Morbid Anatomy. — There is no characteristic lesion of typhus fever. 
According to Murchison, in about two-thirds of the cases the spleen is 
hyperplastic and softened, and not rarely there are enlargement and 
softening of the liver. Various secondary lesions of the mucous and 
serous membranes are common, and almost invariably there is pro- 
nounced hyperemia in the lower lobes of the lung. The blood is dark 
and coagulates with great difficulty 

Symptomatology. — The i3eriod of incubation of typhus fever is 
usually put down as twelve days, but may be much longer or much 
shorter. During this stage the symptoms are very slight ; the disease 
in most cases commences suddenly with a chill, followed by an imme- 
diate rise of temperature, which may reach 105° or 106° F. on the 
second day. During the next ten or twelve days there is no remission 
of the fever, but the evening temperatures are from two to four degrees 
higher than those of the morning. At the end of the tenth or twelfth day 
the temperature usually falls, not with the absolute abruptness of a 
pneumonic crisis, but in the course of two or three days. In fatal cases 
it is common for death to be preceded by a sudden rise of temperature to 
a great height, even 108° F. 

The general symptoms of typhus fever develop almost as rapidly as 
the fever ; the pulse is full and quick but soft, and only in rare instances 
dicrotic ; from the first it lessens in power more and more as the disease 
progresses. A constant phenomenon even in the earliest stage is the 
typhus face, which is characterized by the dark reddish, almost cyanotic 
tint not only of the face itself, but also of the conjunctiva, and by its 
heavy, stuporous expression. The tongue, which is whitish and moist, 
soon becomes dark and assumes a brownish color, corresponding with 
the ever-increasing sordes about the teeth. A peculiar odor, resembling 
somewhat that of putrefaction, is given forth from the skin, with the 
breath, or with the excretions. The violent headache, and the atrocious 
pains in the back and in the limbs, which mark the onset of the disease, 



INFECTIOUS DISEASES. 



147 



may continue until they are lost in a stupor, which is commonly broken 
by a low, muttering delirium. 

The mental state varies greatly in different cases, or sometimes from 
day to day in single cases. A wild raging mania may break forth, or an 
hallucinatory delirium with a never-ending rapid succession of visions, 
with extreme agitation and emotional excitement, may closely simulate 
delirium tremens and give rise to attempts at escape, to assaults upon 
care-takers, who are mistaken for tormenting demons, and even to suicide 
as a means of escape from haunting melancholia. Earely the delirium 
takes the form of a sustained mental effort ; the hours will be spent in 
wild harangue to an imaginary audience upon a religious or other topic. 

Usually on the third or fourth day, although sometimes delayed until 
the eighth, the eruption appears upon the front of the chest and abdo- 
men and rapidly spreads, so that in two or three days it covers the 
whole body. At first glance it suggests the rash of measles, but when 
closely studied it will be found to consist of rose-colored spots, which at 
first disappear upon pressure but soon become petechial, and of a fine, 
irregular, dusky-red mottling, which looks as if it were beneath the sur- 
face of the skin and were seen through a semi-opaque medium. As the 
disease progresses the rash becomes more and more distinctly hemor- 
rhagic, until it takes the form of small, irregular, petechial patches. 

During the second week of the disease there are extreme prostration, 
a rapid, feeble pulse, subsultus tendinum, carphologia, and, it may be, 
a tendency to sloughing of the buttocks, heels, and other parts exposed 
to pressure. Almost invariably bronchial irritation and pulmonic con- 
gestion are present in the beginning of a typhus fever, and not rarely 
they increase until they become a serious element of danger. 

Pronounced abdominal symptoms are rare in typhus fever, and when 
they do occur are to be looked upon rather as accidental than character- 
istic. The anorexia is complete, but there is generally no active disgust 
for food. There is no meteorism, and no abdominal tenderness. In some 
epidemics diarrhoea has been present, but ordinarily the bowels are con- 
stipated, the stools being normal in color and consistency. If perchance 
they are licxuid they are usually dark-greenish, never being of the ochre- 
yellow of the typhoid stool. The spleen may or may not be enlarged, and 
deep upward pressure will sometimes reveal hepatic tenderness. The 
urine is scanty and may in somewhat exceptional cases be albuminous, 
but nephritis is very rare. There is the usual febrile increase of urea 
and uric acid, with lessening of the chlorides. . 

Typhus fever is as a disease much more uniform and self-consistent in 
its course than is typhoid fever, varying chiefly in intensity. It may be 
so slight that the diagnosis is uncertain ; it may be so malignant that the 
patient dies in profound exhaustion as early as the second or third day, 
covered with petechia from blood destruction. 

The convalescence from typhus fever is usually rapid and free from 



148 



GENERAL DISEASES. 



complication, though it may be interrupted by septic purulent inflam- 
mations, such as parotitis and abscesses, or very rarely by paralysis due 
to neuritis. 

Diagnosis. — The abrupt onset, the rapid development of the fever, 
the peculiarities of the eruption, the absence of abdominal symptoms, 
the presence of the peculiar odor of the disease, so clearly separate the 
disease from typhoid fever that in the ordinary case there can be no diffi- 
culty in the differentiation. More difficult of separation would seem to 
be cerebro -spinal meningitis, especially in view of the fact that in some 
cases of typhus there is early in the disease a wide-spread and very pro- 
nounced hyperesthesia. Under these circumstances it may be neces- 
sary for a time to reserve opinion until retraction of the head or other 
local evidence of basal brain inflammation is distinct. Malignant small- 
pox may resemble for a time a foudroyant typhus, but is usually early 
associated with some papular eruption and with hemorrhage from the 
various mucous membranes. From measles typhus fever is to be sepa- 
rated by the greater severity of the constitutional disturbance, by the 
absence of conjunctival irritation, and by the fact that the eruption is 
darker in color, not crescentic, and appears first on the body (not on the 
face). 

Prognosis. — The mortality of typhus fever varies in different epi- 
demics. In nearly eighteen thousand cases treated in the London Fever 
Hospital during twenty-three years the deaths averaged one in 6.34, but 
in certain epidemics the mortality has risen as high as thirty or even 
more per cent. The disease is said to be more fatal in men than in 
women, and its gravity is greatly increased by the existence of alcoholism, 
any constitutional feebleness, or previous disease. 

The age of the patient is a very important factor in the prognosis. 
Under five years of age the mortality in the London Fever Hospital has 
been 67 per hundred, decreasing rapidly, so that between ten and fifteen 
years it was 10.3 per hundred, and then increasing between fifteen and 
twenty years to 45 ; from twenty to forty years, 35.3 ; from forty to fifty 
years, 43.5 ; from fifty to sixty years, 53.9 ; above sixty years, 67. 

The prognosis is grave in proportion to the evident severity of the 
attack ; early extreme adynamia, with muscular tremblings and carpho- 
logia, represents a very dangerous condition. Spasmodic, irregular respi- 
ration, a pronounced myosis, great violence of cerebral disturbance, 
paralysis of the sphincters, a very profuse and very dark eruption, coma 
vigil, early and complete failure of the first sound of the heart, — each and 
all of these are of most serious import. 

Treatment. — There is no specific treatment of typhus fever. The 
management of the case should be upon the same principles as those 
which have been already discussed in the article on Typhoid Fever. It 
is the duty of the physician to see in detail that by most careful nursing 
the patient's strength is saved as much as possible and bed-sores pre- 



INFECTIOUS DISEASES. 



149 



vented. Alcohol is better borne and should be given in larger quantities 
in an ordinary case of typhus than in one of typhoid. The bowels should 
be kept freely open. Food should be given in the form especially of con- 
centrated broths and carefully prepared hashes, eggs, and milk, in as 
large quantities as can be digested, whilst the various symptoms must be 
met as they arise. Depressing remedies are under all circumstances 
contra- indicated. 

RELAPSING FEVER. 

Definition. — A contagious febrile disease, produced by the presence 
in the blood of the spirillum (Sjrirochcete) of Obermeier, and character- 
ized by a succession of febrile paroxysms and remissions, each of about 
six days' duration and recurring from two to four times. 

Etiology. — The immediate cause of relapsing fever appears to be the 
spirillum which was discovered in 1873 by Obermeier. The contagium 
is capable of producing the disorder without any predisposing causes. 
Indeed, it seems doubtful whether much importance can be attached to 
filth, famine, and overcrowding. The contagium may be communicated 
directly from person to person or may be carried in various fomites. It 
seems to be rather less acute and enduring than the contagia of typhus 
and scarlet fever. Neither age, nor sex, nor race, nor season has dis- 
tinct etiological influence. In India relapsing fever seems to be almost 
endemic. Violent epidemics of it are known to have occurred in Europe 
in the early part of the eighteenth century, and in 1844 the contagium 
seems to have been imported into North America by emigrants. The 
latest visit appears to have been in 1869. 

The micro-organisms of relapsing fever are extremely delicate, actively 
motile, spiral fibres, whose length is from three to seven times the diame- 
ter of the red blood-corpuscles. They have been detected in the blood 
only during the paroxysms of fever, but small, glistening bodies which 
are believed to be their spores have been found during the remissions. 

Morbid Anatomy. — Hyperplasia of the bone-marrow and of the 
spleen, with cloudy swelling in the liver, kidneys, and heart, and granu- 
lar degeneration, with the presence of infarcts in various organs, are 
lesions which have been noted after death from relapsing fever, but which 
cannot be considered in any way characteristic. 

Symptomatology. — The period of incubation usually is from five to 
eight days, but in some cases has appeared to be twenty-four hours. The 
attack begins abruptly, with chill, general aching pains, often with vomit- 
ing and vertigo, and sometimes with convulsions. The bodily tempera- 
ture rises very rapidly, and may reach 106° F. during the twenty-four 
hours. It is accompanied by a rapid, full, bounding pulse (110 to 120), 
by free sweating, violent cephalalgia, insomnia, great muscular pains, 
hyperesthesia, marked tenderness of the nerve- trunks, and in some cases 
delirium, especially in alcoholics. There are usually loss of appetite, of! en 
vomiting, and not very rarely diarrhoea, though constipation is the rule. 



150 



GENERAL DISEASES. 



The fever is in typical cases steadily maintained nntil the fifth or sixth 
day, when there is an abrupt defervescence, accompanied by a profuse 
sweating or sometimes diarrhoea. This crisis is sometimes deferred for 
ten or even more days, and sometimes develops as early as the third day. 
In persons of feeble constitution subnormal temperature and collapse are 
not rare. 

The convalescence is immediate, the patient getting up at once. On 
the fourteenth day of the disease there is generally a return of the chill, 
with abrupt fever and the other phenomena of the paroxysm. This 
second paroxysm is, as a rule, shorter than the first, and by a series of 
recurrences the patient may be left profoundly exhausted. Among the 
symptoms which are often seen in the disease may be mentioned jaundice, 
epistaxis, hypostatic congestion of the lungs, nephritis, acute enlargement 
of the spleen sometimes ending in abscess, and very rarely hemorrhage 
from the mucous membranes. During convalescence ophthalmia, post- 
febrile paralysis, rheumatoid arthritis, and purulent otitis media have 
been noted. 

Diagnosis. — The diagnosis of a typical case of relapsing fever can 
scarcely go wrong, but in the beginning of an epidemic and in the early 
stages of the disease it may be impossible to separate the disorder from 
an anomalous typhoid, save by detecting the organism in the blood. 

Prognosis. — Usually relapsing fever has a death-rate of not over 
four per cent., but in certain epidemics, and especially when the epidemic 
has occurred among a people enfeebled by famine and chronic disease, 
the mortality has been very large, rising as high even as fifty per cent. 
Prolongation of the pyrexia, symptoms of intense exhaustion, active de- 
lirium, convulsions, and the development of any severe complication, are 
all evidences of danger. 

Treatment. — There is no known way of aborting a paroxysm of 
relapsing fever or of preventing its recurrence. Quinine is entirely with- 
out influence. The treatment is restricted to careful nursing and feeding 
and the meeting of symptoms as they arise. Isolation of the patient and 
rigid disinfection of the clothing are essential to prevent the spread of 
the disease. The subject should be absolutely confined in bed, not only 
during the paroxysm, but during the intermission, and be fed freely 
with milk, broths, and other light food. For the pains in the back, 
opium, hypodermically or by the mouth, should be used pro re nata. 
Salicylates of all kinds are injurious, and are to be absolutely avoided. 
The bromides are also too depressing, but chloral, trional, and sulphonal 
may be carefully used when there is great wakefulness. Alcoholic and 
other stimulants are to be freely given when there is much prostration. 
The hyperthermia is much better met by the use of cold baths than 
by the administration of antipyrin or other remedies of its class. No 
especial attention should be paid to jaundice when it arises, but gastro- 
intestinal irritation must be carefully treated. After the crisis active 



INFECTIOUS DISEASES. 



151 



treatment of the collapse with strychnine, cocaine, atropine, digitalis, 
alcohol, and other stimulants is often essential. 

ACUTE INFECTIOUS JAUNDICE. INFECTIOUS FEBRILE ICTERUS. 

BILIOUS TYPHOID. 

Definition. — An infectious febrile disease, characterized by fever, 
jaundice, splenic enlargement, and, frequently, nephritis. 

Under the name of typhus biliosus Griesinger observed and described 
in Cairo, in 1850, an infectious febrile disease, which closely resembles 
— indeed, is probably identical with — that to which attention was espe- 
cially directed in 1886 by Weil, and which has been designated as Weil's 
disease. 

Etiology. —This disease occurs especially in summer, and in locali- 
ties where there is faulty drainage. Thus, in the famous Ulm epidemic 
it was ascribed to swimming in foul water. It usually, but not always, 
occurs in local epidemics, and especially attacks young males. In 1892 
Neelsen discovered in the bodies of persons dead of the disease a pecu- 
liar bacillus ; whilst H. Jager in the same year described as coming from 
the same source Bacillus proteus fiuorescens, and Bosc has found Staphy- 
lococcus aureus in fluid taken from the liver by aspiration during life. 
The etiological value of these organisms is doubtful. 

Morbid Anatomy. — The lesions are those characteristic of infection. 
A granular, in part fatty, degeneration of the cells of the liver and kid- 
neys, and circumscribed collections of leukocytes, occur in these organs. 

Symptomatology. — The disease is announced by a sudden chill, 
followed by a rapid elevation of temperature to 104° or 105° F. It 
remains thus elevated until between the fifth and eighth days, when it 
falls by steps, the normal temperature being reached between the tenth 
and twelfth days. In about one-fourth of the cases a recurrence of the 
fever takes place within the subsequent week, milder than the original 
attack and lasting five or six days. Headache and dizziness are of early 
occurrence, and restlessness, delirium, stupor, and prostration follow. 
Severe pains are complained of in the nape of the neck, the back, and the 
calves. There are loss of appetite, nausea, perhaps vomiting. Diarrhoea 
or constipation may be present. Mild jaundice occurs early, and lasts 
perhaps a fortnight. At the end of the first week roseola, erythema, 
and herpes are frequent. There may be epistaxis, sore throat, or bron- 
chitis. The pulse varies from 100 to 110 in the early part of the disease, 
but falls with the occurrence of jaundice, and may become subnormal. 
The fa3ces are pale, sometimes colorless. The urine contains albumin, 
red and white blood- corpuscles, and hyaline and epithelial casts. With 
the occurrence of the jaundice the liver becomes enlarged and tender 
and the spleen enlarged. 

In severe cases violent hemorrhage may occur from the various 
mucous membranes, with wide-spread ecchymoses. Herpes, erythema, 



152 



GENERAL DISEASES. 



parotitis, various catarrhs, pneumonia, and peripheral neuritis may de- 
velop as complications or sequelae, and the convalescence is usually so 
slow that two or three months are required for the restoration of health. 

Diagnosis. — The physical and rational signs are indicative of an 
acute infectious process, in which jaundice is conspicuous and the range 
of temperature is characteristic. The enlargement and tenderness of the 
liver and spleen, and especially the occurrence of the disease in small 
epidemics, are characteristic. 

Prognosis. — The mortality-rate has varied in different epidemics or 
groups of cases from ten to thirty per cent. Death may occur early or 
late in the disease. 

Treatment. — The treatment of infectious icterus is that of any gen- 
eral infection, — i.e., symptomatic and supporting. 

CEREBRO-SPINAL MENINGITIS. SPOTTED FEVER. 

Definition.— A febrile disorder, occurring in wide-spread or local 
epidemics, characterized pathologically by a cerebro-spinal meningitis and 
a pronounced tendency to the destruction of the blood, and clinically by 
a very variable course, during which the most marked symptoms are those 
of meningitis and hsemic disorganization. 

Etiology. — In its etiology cerebro-spinal meningitis is among the most 
mysterious of diseases. Its origin cannot be traced to accumulations of 
filth or other ordinary causes of febrile disease. Most of its outbreaks 
have occurred over periods of from ten to fifteen years, during which time 
both Europe and America have been affected without it being possible to 
detect the travelling of the disease along watercourses or lines of com- 
mercial intercourse. The first known period was from 1805 to 1816 j the 
second/from 1837 to 1850 ; the next, from 1856 to 1864 ; since which time, 
however, there have been scattered epidemics of the disease, which, in- 
deed, may be considered to be endemic in the larger cities of the Northern 
United States. The disease has appeared simultaneously in distant regions 
without traceable connections, is more abundant in winter than in spring, 
and cannot in any way be attributed to known peculiarities of the soil 
or other local causes. It seems, however, to be favored by crowding of 
individuals, so that it is especially prone to appear amid the misery 
and poverty of large tenement-houses, and has been very severe among 
soldiers in garrison towns. It attacks both sexes alike, children more 
frequently than adults. It is not contagious, the attendants of the sick 
are very rarely affected, and there is no evidence that the disease passes 
directly or indirectly from man to man. It is not known to be carried 
by fomites. Long-continued, excessive labors, whether mental or bodily, 
seem to predispose to the attacks. Micrococcus lanceolatus, and also the 
pneumococcus, have been found in the meninges of persons dead of the 
disease, but reliable bacteriological studies of the epidemic disease are 
still wanting. 



INFECTIOUS DISEASES. 



153 



Morbid Anatomy. — In the apoplectiform cases ending fatally within 
twenty-four hours there may be little or no visible alteration of the me- 
ninges, but the brain is swollen, its convolutions are flattened, and the 
furrows are obliterated. The characteristic appearances are to be seen 
towards the second half of the first week and later. They consist essen- 
tially in the manifestations of an acute leptomeningitis, serous, fibrino- 
serous, or purulent. The dura mater is tense, its free surface usually 
unaltered. The outer surface of the pia mater is also usually normal. 
The meshes, however, are infiltrated with a more or less opaque yellow, 
serous, fibrinous, or purulent exudation, which often varies in character 
in different parts of the brain of the same case. The inflammatory exu- 
dation is generally most abundant at the base of the brain and over the 
convexities. In the former region it fills the space between the optic 
chiasm and the pons, and is abundant over the cerebral peduncles and on 
the upper surface of the cerebellum. It may follow the sheaths of the 
auditory and optic nerves. Over the convexities the exudation forms 
opaque yellow parallel lines accompanying the injected veins as they 
overlie the furrows and spreading thence over the cerebral convolutions. 
Minute hemorrhages may be present in the injected pia mater. Similar 
appearances are to be seen in the pia jnater of the spinal cord, either 
throughout or in limited portions. The infiltration is usually more ex- 
treme on the posterior surface of the cord and in the most dependent 
portions, especially in the lumbar region. 

The brain is pale, the convolutions are flattened, and the ventricles are 
distended with an opaque fluid from which yellow, viscid clots settle at 
the lowermost parts, usually the posterior cornua of the lateral ventricles. 
The ependyma is swollen, soft, perhaps ecchymosed. The choroid plex- 
uses are injected. The inflammatory infiltration of the pia mater is ex- 
tended along the perivascular spaces into the cerebral cortex, and minute 
foci of hemorrhagic or suppurative encephalitis may be seen, perhaps with 
the unaided eye. 

If the patient dies during the later stages of the disease the pia mater 
is thickened and opaque in patches and spots and adherent in places to 
the brain. It is somewhat discolored from the presence of blood-piginent. 
The convolutions of the brain may be atrophied and the meshes of the 
pia mater oedematous. 

There are splenic hyperplasia and granular degeneration of the heart, 
liver, and kidneys. Bronchial catarrh is frequent, and atelectasis and 
hypostatic and lobular pneumonias are associated. The lymph-follicles 
of the intestine are swollen. The appearances characteristic of arthritis, 
endocarditis, pleurisy, nephritis, and enteritis are present when these 
affections complicate the course of the disease. 

Symptomatology. — The course and symptoms of cerebro-spinal men- 
ingitis vary so greatly as almost to baffle concise description. The 
number of varieties made by clinical writers is very great, but all such 



154 



GENERAL DISEASES. 



varieties everywhere shade into one another ; and for the purpose of de- 
scription it is probably wisest to recognize only the ordinary type, the 
malignant type, and anomalous forms. 

Ordinary Type. — The premonitory symptoms, such as vertigo, pros- 
tration, feverishness, or chilliness, may be altogether wanting, or may last 
from one to twenty-four hours. In young children convulsions may 
usher in the attack ; in adults the first distinct phenomenon is ordinarily 
a chill, slight or severe, followed at once by excruciating headache, vom- 
iting, vertigo, and a rise of temperature to 101° or 102° F. The pulse 
is slow, full, and strong ; the face is livid, or perhaps pale, with an ex- 
pression of great anxiety. As the hours go by, the headache increases 
in severity and becomes associated with a violent backache, as well as 
with a contraction of the neck-muscles and marked pain when the head 
is forcibly flexed. The motor disturbances grow more and more de- 
cided until the muscles of the back are rigidly contracted, as in teta- 
nus. Trismus is not uncommon ; tremors of the muscles may be pres- 
ent ; or more frequently tonic or clonic spasms invade the extremities. 
The muscles of the eye and face do not escape, so that strabismus and 
facial spasms are frequent. Delirium may follow immediately upon the 
chill, and is almost invariably an early symptom. It may be wander- 
ing, but is often furious and maniacal. Sometimes from the first it is 
wanting, and ordinarily it gives place in a few days to an increasing 
stupor. 

The special senses are affected ; severe tinnitus aurium may be an 
early symptom ; in the advanced stages of the disease deafness is almost 
universal. Double vision is an ordinary result of strabismus ; choked 
disk and failure of eyesight frequently mark the excessive pressure at 
the base of the brain. In the last stages sometimes the pulse becomes 
slow and irregular from pneumogastric irritation, whilst Cheyne-Stokes 
breathing may result from the disturbance of the respiratory centre. 

The symptoms thus far enumerated are in great part a direct outcome 
of the meningitis, and are not so characteristic of the disease as are the 
skin eruptions. Herpes, especially herpes labialis, is very frequent and 
persistent, but the pathogenic eruption is that of petechias which cover 
the whole surface of the body, beginning as small, bright, deep rose or 
purplish spots or occurring in patches of various sizes, and in severe 
cases coalescing into great blotches over large territories. This erup- 
tion may develop as early as the third day, or it may be put off as late 
as the eighth. It is a striking feature in some epidemics, whilst in 
others it is almost altogether absent. Taking all the cases together, it 
probably occurs in about one- third. In some epidemics it has been re- 
placed or accompanied by urticaria, scarlatinoid or rubeoloid rashes, and 
even pemphigoid bullae. 

The abdominal symptoms in cerebro-spinal meningitis are not pro- 
nounced. Vomiting is usually present in the beginning, and may occur 



INFECTIOUS DISEASES. 



155 



at any stage of the disease. Ordinarily there is constipation. Enlarge- 
ment of the spleen is sometimes demonstrable. 

The average temperature of cerebro- spinal meningitis is distinctly 
lower than that of most of the serious continued fevers ; it may range, 
even in severe cases, below 100° F. ; rarely does it reach above 103° F. 
It may, however, especially in fatal cases, mount up even to 107° F. 
Exacerbations of pain are often accompanied by rise of temperature. 
The differences between the morning and the evening temperature may 
be very great, but may be wanting. Sometimes the maximum tempera- 
ture occurs in the morning. The only characteristic features of the tem- 
perature curve are its great irregularity and its failure to follow any 
definite course. 

Malignant Form. — There are two chief varieties of malignant epi- 
demic meningitis. In the apoplectic or cerebral type the symptoms are 
violent headache, rapidly developed delirium with or without retraction 
of the head, great vital depression, moderate elevation of temperature, 
and a feeble pulse, which may be slow or rapid. Death in coma may 
occur within six or eight hours. In the second type there is vital de- 
pression, with moderate or high temperature, and the almost immediate 
appearance of ecchymoses on various parts of the body, rapidly spread- 
ing and involving the whole surface in dark purple spots, with clearness 
of intellect, and death within twenty-four hours. There are cases in 
which the symptoms of these two typical varieties are intermingled ; and 
every grade of case between the most malignant and the ordinary form 
occurs. 

Anomalous Forms. — Among the anomalous forms which have been 
described is that which is sometimes known as the intermittent type, 
in which the fever is remittent or intermittent, with paroxysms which 
recur daily or every second day. A second variety is that which may 
be termed the neuralgic or rheumatoid, in which the pains in the legs 
and arms are extremely violent, accompanied by 'great hyperesthesia, 
and it may be excessive pain on movement, and even by pronounced 
redness and swelling of the joints. It is probable that in these cases there 
is a peripheral neuritis, although this has not been demonstrated. There 
are two abortive forms, — one in which the symptoms are throughout very 
mild (" walking cases"), and one in which the onset may be furious, 
with very threatening symptoms and high temperature, which, however, 
subside after a few hours, or at the most in three or four days, and leave 
no abiding ill effects. 

Another form of the disease is that which has been especially com- 
mented upon by Heubner as the chronic, in which the course is protracted 
over many months, with remissions, intermissions, and recurrences of the 
fever, and with very varying symptoms. In most of such cases there are 
pronounced evidences of basal meningitis, with great loss of strength and 
wasting. The symptoms are chiefly maintained by the local disease of 



156 



GENERAL DISEASES. 



the brain and its membrane, and not rarely there is an occlusive menin- 
gitis (see page 490) with its concurrent hydrocephalus. 

The course of epidemic meningitis is entirely irregular from day to 
day, and also in its duration. In fatal cases death usually happens from 
the fourth to the seventh day, but it may occur almost immediately or 
be postponed beyond a month. Largely owing to the local changes, 
even in favorable cases, convalescence may be prolonged almost indefi- 
nitely, and is usually accompanied by gradually subsiding symptoms 
of meningitis, not rarely interrupted by relapses. Permanent loss of 
hearing is very common, producing in young children deaf- mutism. Par- 
tial or complete amaurosis is not rare ; weakness or loss of memory, 
general impairment of intelligence, and even chronic hydrocephalus, 
various local paralyses, disorders of speech, and epileptic attacks, are 
among the sequelae of the disease. 

Diagnosis. — The diagnosis of cerebro- spinal meningitis is, during an 
epidemic, ordinarily not difficult. In sporadic cases it is essential to 
determine the non-existence of tubercle, otitis media, syphilis, or other 
cause for an existing meningitis which has been recognized. The pres- 
ence of herpes or of any non- syphilitic skin eruption is usually in favor 
of the epidemic disease. The symptoms may so resemble those of typhoid 
fever, or of rheumatism, or of pneumonia with meningeal symptoms, as 
to require great care on the part of the practitioner to avoid mistake. 
The shifting irregularity of the symptoms, the peculiarities of the tem- 
perature range, the failure of conformity of the febrile and other mani- 
festations to the type of the pneumonia or the typhoid or whatever other 
disease may be simulated, should excite suspicion ; whilst the exist- 
ence of distinct stiffness in the neck under such circumstances must be 
looked upon as decisive. A septic meningitis is to be made out by find- 
ing the point of infection. The type or form of a cerebro -spinal menin- 
gitis may shift during the attack, and pneumonia, or at least pulmonic 
congestion, may in the beginning be very misleading. We have seen a 
case diagnosed first as pneumonia and then as rheumatism by excellent 
practitioners, who ought to have been put upon their guard by the shift- 
ing, uncertain character of the symptoms. 

Prognosis. — The prognosis is unfavorable in direct proportion to the 
severity of the symptoms, but should always be guarded, as sometimes 
apparently mild cases suddenly take on an unfavorable course, whilst 
recovery may occur out of a condition of apparent hopelessness. The 
mortality varies in different epidemics from twenty to seventy-five per 
cent., probably averaging about thirty per cent. Petechias, although a 
serious symptom, are not as unfavorable as are marked evidences of 
meningeal inflammation. 

Treatment. — Cerebro-spinal meningitis should be treated in accord- 
ance with the general principles that govern the management of infec- 
tious fevers. The nursing should be most careful, and the saving of the 



INFECTIOUS DISEASES. 



157 



patient's strength most rigorous ; whilst the diet should be simple, nu- 
tritious, and up to the digestive powers of the individual patient, milk, 
animal broths, eggs, oysters, and farinaceous foods being given pro re 
nata. 

At one time venesection was largely practised in robust cases, and it 
has been strongly advised by various physicians. It seems to us, how- 
ever, distinctly contra- indicated, and we have never seen a case in which 
its use was justifiable. The local abstraction of blood by means of leeches 
or cups to the temples or the back of the neck is affirmed by Stille and 
others in many cases greatly to mitigate the pain and distinctly to relieve 
the local disease. Even local blood-letting should be, however, prac- 
tised with caution, and in our experience its free use is rarely justifiable. 
Blisters have been largely used and strongly commended. It is plain 
that the most that can be accomplished by them is relief of the menin- 
geal and cerebral congestion, and that there is danger, if they be used 
too severely, of producing violent local inflammations, which may, as 
the dyscrasia of the disease becomes more and more developed, take on 
a very serious form. Vesication should, therefore, always be superficial, 
and in order to be effective must cover a large surface. It is to be 
entirely avoided when the symptoms of breaking down of the blood are 
pronounced. The best site for the blister is from the nape of the neck 
upward over the occiput. The continuous application of cold by means 
of ice-bags to the head and upper spine is of great importance, and 
probably has as much effect upon the local disease as has local blood- 
letting or counter-irritation. 

In the older epidemics American physicians were accustomed to pro- 
duce violent diaphoresis for many hours by the use of external warmth, 
aided by hot infusions of aromatic herbs and other drugs, and many 
writers affirm that in this way the disease can be aborted. This does not 
seem in accordance with our present knowledge of febrile disorders, and 
the practice has been generally abandoned. 

As the disease progresses, the symptoms should be met as they arise. 
When there is high temperature, cold may be employed as in typhoid 
fever. There is much testimony as to the especial value of opium, for 
which an extraordinary tolerance usually exists, and which should be, at 
least in part, preferably given hypodermically in such doses as to main- 
tain a very mild narcotism. Yon Ziemssen affirms that morphine is the 
indispensable medicine in the treatment of the disease. Quinine has also 
been largely used, but is probably more powerful for evil than for good. 
Calabar bean, potassium bromide, chloral, ergot, and various medicines 
acting upon the nerve-centres have been strongly commended, and as 
strongly condemned. None of them have any definite effect upon the 
disease, but some of them may aid from time to time in the mitigation 
of harmful symptoms. Thus, chloral may sometimes be useful in the 
quieting of excessive spasm or iu the obtaining of sleep if insomnia 



158 



GENERAL DISEASES. 



exist. Antipyrin and remedies of its class, if employed at all, should 
be used simply as quietants, not for the reduction of temperature. In the 
rheumatoid cases there is a great temptation to administer salicylic acid, 
but in our experience with sporadic cases it has not been useful ; it does 
more harm than good. Alcohol is to be employed in proportion to the 
existence of exhaustion ; laxatives to overcome constipation ; mild diu- 
retics if the renal secretion fail. 

INFLUENZA. GRIPPE. 

Definition. — A contagious febrile disease, especially characterized 
by the enormous extent of its epidemics and by the occurrence of local 
catarrhal symptoms. 

Etiology. — Infectious influenza, although it had almost been for- 
gotten until it broke out in 1889-90, was very fatal during the Middle 
Ages, having, it is said, in 1580 killed nine thousand persons in Borne, 
and in 1780 attacked fifty thousand people in St. Petersburg in a single 
night. It is affirmed to be endemic in the neighborhood of St. Peters- 
burg, and in September, 1889, it began rapidly to advance from the old 
centres in Eussia, reaching Paris by the 26th of November, and thence 
spreading over the whole civilized world. We believe it to be con- 
tagious. It travels especially along lines of water or railroad con- 
nections, and has been noted both in Paris and in Philadelphia to form 
foci in the great retail mercantile establishments, from which it soon is 
scattered over the whole community. At the same time the disease 
apparently travels independently of contagion, as ships at sea have 
entered belts of it, almost the whole crew being stricken down in a night. 

The nature of its cause has not been demonstrated, although in 1892 
Canon and PfeifYer discovered simultaneously in the blood and in the 
bronchial discharges of patients suffering from influenza a very minute 
bacillus, occurring singly or in chains, which they believe to be the germ 
of the disease. Neither age nor sex seems to have much influence as a 
predisposing cause. It is affirmed that the disease spreads to animals ; 
but this is certainly contrary to what has happened in this country. 

Morbid Anatomy. — In influenza death almost invariably results 
from local complications, so that the only changes found at the autopsies 
are those of the complications. 

Symptomatology. — Infectious influenza is a very polymorphic dis- 
ease ; the varieties depend chiefly rather upon the local manifestations 
than upon the constitutional symptoms. The onset is usually sudden ; 
in some cases the attack is ushered in with a distinct chill, in which 
there may be pronounced delirium or other severe nervous symptoms. 
Almost invariably there are violent pains in the back, limbs, and extrem- 
ities, a peculiarly intense weakness, whose severity is out of proportion 
to the other symptoms, and fever. From this point the cases diverge : 
five distinct varieties of the disease are met with. In the typhoid form 



INFECTIOUS DISEASES. 



159 



there is a continuing fever, with extreme languor, wide-spread muscular 
pains, and severe nervous symptoms, such as stupor or delirium, and 
the rapid development of the dry tongue and general manifestations of 
a typhoid state ; even in these cases, however, there is usually some 
catarrh or other local complication. The cardiac form of the disease 
may be considered to be a modification of the typhoid ; in it there is an 
alarming cardiac failure, with very rapid and often broken, feeble, it may 
be intermittent, pulse, and sometimes with cardiac distress, although the 
subjective sensations of heart-failure are usually less severe than are the 
objective symptoms. The third variety of influenza is the more ordinary 
one, in which there is wide-spread severe respiratory catarrh, involving 
the whole mucous membrane of the lungs, and having a great tendency 
to pass into capillary bronchitis or catarrhal pneumonia : coryza, hoarse- 
ness or suppression of voice, violent cough, and the ordinary physi- 
cal symptoms of pulmonary disease may overshadow the constitutional 
affection. In the gastro-intestinal form, in addition to the constitu- 
tional symptoms there is pronounced abdominal disturbance ; this usu- 
ally takes the form of very severe serous diarrhoea, accompanied by 
very large and frequent watery passages, without vomiting and without 
pain ; in some cases, however, there is much vomiting, and in others 
pronounced abdominal pain. In the so-called^ rheumatoid type the pains 
are exceedingly violent and persistent, and seem to be localized in the 
muscles and muscular attachments, neither the joints nor the nerve- 
trunks showing tenderness to pressure or change to the eye. 

Although typical cases of each of these varieties are abundant during 
an epidemic, very commonly the symptoms are so intermingled and 
changeable that it may be impossible to decide in which category to 
place the individual case, or the same case may on different days belong 
in different subdivisions. 

The intensity of grippe varies, from a condition in which it is uncer- 
tain whether the subject should or should not be considered sick, to the 
most alarming state. In the mildest cases there is only a slight evening 
rise of temperature ; in the average case the fever ranges from about 
101° F. in the morning to 102° F. in the evening ; in the severest cases 
the maximum may be 105° or 106° F. The temperature curve is apt 
to be entirely irregular, with depressions and elevations, sometimes to be 
accounted for by the local complications, often, however, without ap- 
parent cause. The average duration of the disease is from three to ten 
days ; when there are severe local complications the course may be 
long protracted, and sometimes, even if there be no settled local lesions, 
the disease holds on for several weeks. In some cases there is a sudden 
ending with a sort of crisis ; more commonly the patient passes into con- 
valescence so gradually that it is impossible to say when the disease 
should be considered to have ended. The convalescence from even the 
mildest influenza is apt to be exceedingly slow j the pains and local 



160 



GENERAL DISEASES. 



disturbances are often very obstinate, but much more enduring are 
the weakness and inability not only for physical but also for mental 
exertion, which may last for months. 

Complications. — The great danger in influenza is from the occurrence 
of complications. Of these the most frequent and most fatal are the 
pulmonary. Extensive catarrhal pneumonia, with symptoms of great 
oppression, pale cyanotic countenance, violent cough, and high fever, is 
common. The sputum is apt to be copious and dense, but the character- 
istic rusty sputum of true fibrinous pneumonia is exceptional. The pneu- 
monia diplococcus and streptococcus can usually be found. Pleurisy with 
large serous or more rarely purulent effusion is not rare. Pericarditis 
occasionally develops, and, in very bad cases, pneumonia, pericarditis, 
and pleuritis may coexist. Among the rarer complications may be men- 
tioned purulent inflammation of the middle ear and of the conjunctiva, 
or even of the eye itself. Furuncles, localized abscesses, peripheral 
neuritis, and various skin eruptions, such as herpes, urticaria, roseola, 
etc., are occasionally developed. Confusional insanity of melancholic 
or maniacal type may follow the attack. 

Diagnosis. — Although the symptoms of a mild influenza cannot be 
distinguished from those of a simple cold, during the prevalence of an 
epidemic of the disease the diagnosis of influenza is the safer, and is 
justifiable in all cases resembling the typical disease. The chief symp- 
tomatic difference between an infectious influenza and a climatic catarrh 
is that in the influenza the malaise and disturbances of temperature pre- 
cede the local disease and are entirely out of proportion to its extent. 

Prognosis. — The prognosis in influenza, so far as ultimate recovery is 
concerned, is good, provided the subject be not debilitated and proper 
care be taken to avoid complications. When such complications arise 
the prognosis becomes grave in direct proportion to the gravity of the 
local disease. 

Treatment. — In treating a case of influenza it must be remembered 
that four-fifths of the deaths from the disease occur from exposure, and 
that the slightest influenza is a serious disease, requiring confinement to 
bed and careful nursing. In the majority of cases the attack can be 
greatly and immediately ameliorated by free sweating, which is best pro- 
duced by a mixture of aconite, antipyrin, and pilocarpine. (See formula 
7.) A dessertspoonful of this may be given, the patient put in a bath of 
105° F. for ten minutes, taken out, and given a strong, hot toddy with a 
teaspoonful of the mixture, the latter to be repeated in half an hour if 
sweating does not come on. For those individuals in whom morphine 
does not produce after-depression one-eighth to one-quarter of a grain 
of the alkaloid may be added to the mixture. The sweating may be 
induced in various other ways : hot toddy and Dover's powder, aided by 
the hot bath, will usually suffice, and is preferable when there is pro- 
nounced cardiac weakness. In the ordinary case of influenza all that 



INFECTIOUS DISEASES. 



161 



is required after the sweating is the use of moderate doses of quinine, 
five to ten grains a day, and the administration of cocaine and strych- 
nine in tonic doses. The food should be nutritious and simple, and 
given at intervals of not more than four hours. Small quantities of 
alcoholic drinks given with food are often very beneficial. The greatest 
care must be exercised in allowing a patient to go out when conva- 
lescence begins, as the liability to catarrh may continue for an almost 
indefinite period. 

In gastro-intestinal influenza the food should be at once reduced to 
boiled milk slightly thickened with flour, animal broths with or without 
egg, toast, and tea. Opium should be used freely ; bismuth with car- 
bolic acid, or aromatic sulphuric acid diarrhoea mixture (formula 6), or 
a chalk mixture (formula 8), may be used. Chlorodyne or a mixture 
of chloroform, camphor, and an aromatic oil is sometimes very ser- 
viceable. (See formula 9.) Slow, long-acting counter-irritation over the 
abdomen by means of weakened mustard or spice plasters should also 
be employed. 

The pulmonic catarrhs are to be treated as they would be if arising 
from other causes, but the type of the disease is always distinctly ady- 
namic. Tartar emetic should never be given, but if secretion be not 
free the potassium citrate mixture with apomorphine may be used ; after 
this ammonium chloride sometimes acts well ; but usually, after free secre- 
tion has been established, the best results are obtained with oil of eucalyp- 
tus or with terebene. In obstinate catarrhs, guaiacol, compound tincture 
of benzoin, or syrup of garlic may be essayed. Free, persistent, and exten- 
sive counter-irritation is always valuable. High temperature rarely 
needs treatment, because it is not long sustained. If, however, 104° F. is 
reached, sponging or the tepid bath may be employed, and if these fail of 
effect, cold baths may be given. Phenacetin and antipyrin are sometimes 
serviceable as antipyretics, and also as quieting pain and other nervous 
disturbances, but under no circumstances should they be given in large 
dose, — not over fifteen grains in twenty-four hours. When there is 
heart-failure, alcohol (in moderation), strychnine, cocaine, tincture of 
strophanthus, and tincture of digitalis are to be employed. Sometimes 
it is necessary to give very large doses, and when there is a tendency 
to vomiting or the symptoms are alarmingly acute, cocaine and strych- 
nine may be used hypodermically. We have also seen life apparently 
saved by the hypodermic use of tincture of digitalis (ten to twenty 
minims). 

DENGUE. BREAK-BONE FEVER. 

Definition. — An epidemic, contagious fever of subtropical coun- 
tries, characterized by violent muscular and articular pains and a poly- 
morphous rash. 

Etiology. — Epidemics of dengue have been noted in subtropical 
Asia, Europe, and America. J. W. McLaughlin states that he has found 

ll 



162 



GENERAL DISEASES. 



a peculiar micrococcus in the blood. The disease is immediately con- 
tagious. An extraordinary feature is the fact that usually four-fifths 
of the whole population exposed take the disease. 

Morbid Anatomy. — Death from dengue being almost unknown, 
there is no knowledge of lesions produced by the disease. 

Symptomatology. — After a period of incubation varying from some 
hours to five days, dengue commences abruptly with very severe aching 
pains, headache, and a more or less pronounced chill, followed by fever, 
which usually reaches its maximum during the first twenty-four hours. 
In severe cases there are rapid pulse, general adynamia, and even noctur- 
nal delirium. Loss of appetite is universal ; mucous or bilious vomiting 
is very common. Yery frequently there appears almost at once an ery- 
thematous rash, which may invade the mucous membrane, producing 
redness and swelling of the conjunctiva, of the internal nares, and of the 
throat. Both large and small joints are affected, and often become swol- 
len and red by the third or fourth day. In from forty-eight to sixty 
hours a rapid defervescence occurs, often accompanied with critical phe- 
nomena, such as colliquative sweat, diarrhoea, and epistaxis. At this 
time, in a large proportion of the cases, develops the so-called secondary 
or terminal rash of the disease, which is characterized by its polymor- 
phism. It may be papular and circumscribed, or papular and diffused ; 
or it may be vesicular or pustular. More frequently, however, it is an 
exanthem which resembles that of measles or that of scarlet fever, or is 
like an urticaria. Several forms of the eruption may exist in the same 
case. Enlargement of the lymphatic glands is not uncommon. A sec- 
ondary fever may follow the eruption and gradually subside. 

Abortion frequently results in pregnant women, but death from the 
disease is almost unknown, except in very young infants, who sometimes 
die in coma and convulsions. Convalescence may be very slow and pro- 
tracted, with long continuance of the muscular and articular pains, and 
also of the glandular swellings. 

Desquamation follows the secondary eruption, and may be complete 
in six days, but may be protracted to from ten to fifteen days. As no 
known agent is capable of distinctly modifying the course of dengue, the 
treatment must be purely symptomatic. If phenacetin and antipyrin 
fail to control the pains, opium should be used. 

THE PLAGUE. 

Definition. — An extremely contagious, usually epidemic disease, es- 
pecially characterized by an eruption of boils and the formation of buboes. 

In the Middle Ages the plague was of frequent occurrence in wide- 
spread disastrous epidemics. At present it seems to be confined to 
certain districts in Asia and Africa. In 1881 there was a very severe 
epidemic in Mesopotamia, and in 1891 one in Bagdad ; whilst China still 
suffers. 



INFECTIOUS DISEASES. 



163 



Kitasato states that during the Hong-Kong epidemic in 1894 he 
found in the blood, glands, and viscera of the patient a short bacillus 
having rounded ends, whose pure cultures produced, when inoculated 
into animals, a series of symptoms like those of the plague in human 
beings. This bacillus he believes to be the cause of the disease, and to 
be capable of invading the human body through the respiratory and 
digestive tracts, and also through wounds. 

An attack of the plague begins suddenly, with intense headache, ver- 
tigo, dilatation of the pupils, great anxiety and general depression, end- 
ing, in from a few hours to some days, in a violent chill, followed by 
high fever, with excessive prostration, vomiting, rapid pulse, accelerated 
breathing, complete anorexia, severe abdominal pain, and not rarely 
diarrhoea. Great nervous disturbances, delirium, coma, bronchial ca- 
tarrh, serious hemorrhages, excessive adynamia, and violent depression of 
the heart, may, in this stage, end in death. If the patient survive, after 
two or three days of fever buboes will appear and proceed rapidly to 
suppuration and ulceration ; whilst, not universally, but very generally, 
boil-like pustules will break out upon the extremities, perhaps ending 
in local gangrene. In favorable cases from the eighth to the twelfth 
day a slow convalescence sets in. The mortality of the ordinary forms 
of the plague is about ninety per cent. In malignant cases death may 
take place during the first day. The only characteristic lesions are the 
bubonic tumors, which always have their origin in lymphatic glands. 

The treatment of the plague must be purely symptomatic. It is doubt- 
ful whether the course of the disease can be in any way modified for the 
better by human agency. 

DIPHTHERIA. 

Definition. — A highly contagious disease, characterized by fever, 
usually by a pseudo- membranous inflammation of the pharynx, and often 
by symptoms of a toxaemia due to the presence of a specific bacillus whose 
growth produces the poison which is absorbed. 

Although epidemics, endemics, and sporadic cases of severe sore throat 
of a probably diphtherial nature are mentioned in early medical writings, 
it was Bretonneau, in 1821, who first included under the term diphtherite 
the disease now known as diphtheritis or diphtheria, and applied this 
term in virtue of the presence of a false membrane, dupOipa. 

Etiology. — Diphtheria occurs in all countries, at all seasons, but par- 
ticularly during the colder months of the year. Its extension is favored 
by the crowding of people in limited quarters, and especially by the pres- 
ence of large numbers of children in schools. McCollom has recently 
emphasized the fact that the number of cases is much greater when the 
schools are in session than during the summer vacation. Predisposing 
causes are to be found in exposure to faulty hygienic surroundings, espe- 
cially filth, dampness, and poor ventilation. McCollom, however, states 



164 



GEKEEAL DISEASES. 



that imperfect drainage and insalubrious conditions are not important in 
increasing the frequency of diphtheria, this disease having been found 
more prevalent in localities in which there was no fault to be found with 
hygienic conditions than in sections where the reverse was the case. 
Children, especially the young, are more prone to the disease than adults. 
Sucklings are rarely affected. Persons debilitated from whatever cause, 
and those liable to recurring attacks of sore throat, are especially suscep- 
tible. 

The immediate cause is universally admitted to be the bacillus dis- 
covered by Klebs in 1883 and obtained in pure cultures in 1884 by Loef- 
fler, who demonstrated its pathogenic importance. This bacillus, the 
Klebs-Loeffler or diphtheria bacillus, is a slender rod, usually slightly 
bent in the middle, its extremities club-shaped and tending to become 
more deeply stained than the other parts. The bacillus inclines to form 
groups of two to five lying parallel. It is usually from 2 to 3 a long and 
from 0.5 to 0.8 fi broad. It is thus nearly as long and twice as broad 
as a tubercle bacillus. It thrives in milk and grows readily upon the 
mixture of blood serum and bouillon recommended by Loeffier, colonies 
being formed in the incubator in the course of twelve hours before any 
considerable growth of associated bacteria has taken place. "When kept 
in darkness in a moist state it lives for months. Its vitality may be 
preserved for a number of weeks in a dried state, as in fragments of 
diphtherial membrane, but it is destroyed by exposure for half an hour 
to a temperature of 140° F. This resistance of the bacillus to atmospheric 
influences satisfactorily explains the occurrence of sporadic cases of diph- 
theria and their occasional origin in rooms in which careful efforts at 
disinfection have been made. Great variations in its virulence exist. 
Bacilli resembling the diphtheria bacillus in every respect except in 
being non- virulent are sometimes found on normal mucous membranes. 
These have been called the pseudo-diphtheria bacillus, but recent inves- 
tigations favor the view that this bacillus is an enfeebled, non-virulent 
diphtheria bacillus, whose vitality and virulence can be restored under 
suitable conditions. The diphtheria bacillus is present upon the in- 
flamed mucous membrane in all cases of diphtheria, and may be found 
months after convalescence from the attack, although usually disappear- 
ing in the course of two or three weeks. We are informed from the 
bacteriological laboratory of the Harvard Medical School that of nine 
hundred and nine cases of diphtheria examined during four successive 
months there were one hundred and sixteen in which diphtheria bacilli 
remained at the end of two weeks. Of these the bacilli were present 
in sixty-three between two and three weeks, in thirty between three and 
four weeks, in eleven between four and five weeks, in seven between five 
and six weeks, in four between six and seven weeks, and in one between 
seven and eight weeks. The bacilli may be found upon the conjunctival 
and genital mucous membranes and upon the wounded surfaces of persons 



INFECTIOUS DISEASES. 



165 



suffering from diphtheria. They also may be found upon the cutaneous 
wounds of persons who have not been exposed to this disease, and, in 
rare cases, upon the mucous membrane of the throat of healthy persons. 
In the dissemination of diphtheria the important element is the transfer 
of the bacillus from one person to another. Persons harboring the diph- 
theria bacillus may be free from the disease, but may transfer the viru- 
lent or non- virulent bacillus which may produce the disease in a second 
individual. 

The diphtheria bacillus is at times to be found among the domesticated 
animals, especially in dogs, cats, cows, and fowl. In cats and dogs the 
associated symptoms are loss of appetite, cough, and emaciation. The 
possibility of the transfer of this disease from such animals and from the 
use of infected milk, as reported by Klein, is to be recognized. 

The diphtheria bacillus is usually stained by Loeffler's solution of 
methylene-blue, —thirty parts of a saturated alcoholic solution of meth- 
ylene-blue in one hundred parts of a solution of caustic potash in water 
(1 to 10,000). After staining for from three to five minutes, wash in 
water. Hunt's method is favored in the Harvard bacteriological labora- 
tory in those cases in which the bacilli present are of a doubtful char- 
acter, or in which there are many cocci and but few bacilli. This method 
decolorizes other bacteria than the diphtheria bacillus and deeply stains 
the club-shaped ends. The prepared cover-glass is stained for thirty 
seconds in a saturated solution of methylene-blue. It is then washed in 
water, dried, and placed for a few seconds in a ten per cent, solution of 
tannic acid. After being again washed and dried, the cover-glass is 
placed for a few seconds in a saturated aqueous solution of methylene- 
orange. After being finally washed and dried, the specimen is to be 
mounted. Gram's method is to be employed for the study of diph- 
theria bacilli in the tissues. 

Morbid Anatomy.— The sore throat in diphtheria may be of a ca- 
tarrhal, a pseudo-membranous, or a gangrenous character. The catarrhal 
inflammation alone may exist, and the pseudo-membranous and gangre- 
nous inflammations are usually associated with the catarrhal variety. 
The presence of the diphtheria bacillus is the only characteristic by 
means of which the diphtherial nature of the process is to be absolutely 
determined. In the catarrhal inflammation the mucous membrane of the 
tonsils, uvula, soft palate, and pharynx is swollen and of a dark-red color. 
Its surface is at times covered with a mucous layer, which is sometimes 
opaque from the presence of abundant leukocytes. The tonsillar crypts 
may contain opaque white or yellow material not projecting above the 
surface, and consisting of cells, granules, and bacteria. The appearances 
above described are not to be distinguished from those occurring in non- 
diphtherial varieties of sore throat and in lacunar or follicular forms of 
tonsillitis, except by the bacteriological examination. 

The pseudo-membranous sore throat of diphtheria affects the regions 



166 



GENERAL DISEASES. 



above described, but extension to the upper surface of the soft palate, 
to the nostrils, pharynx, and larynx, even to the trachea and bronchi, 
occurs. In this variety the bacillus destroys the superficial epithelium 
and promotes exudation from the blood-vessels, in consequence of which 
false membranes are formed. These first appear as spots or patches of a 
gray or grayish- white color, offcenest on the tonsils, and thence spreading 
by continuity and contiguity eventually form a membrane which may 
cover the tonsils, soft palate, and uvula, as well as extend into the ad- 
joining parts. The older the false membrane the more likely is it to 
become discolored by blood, medicines, or food, and then it may assume 
a yellow, green, or brown color. A distinction is drawn by Yirchow 
between a fibrinous and a diphtheritic inflammation of the mucous mem- 
brane in diphtheria. The former is rather membranous than pseudo- 
membranous, and is more often found in the larynx, trachea, bronchi, 
and nose than in the pharynx. It may occur in the air-passages in diph- 
theria either alone or in association with the other anatomical varieties 
of inflammation. It may be found alone in the nose in membranous 
rhinitis, in which affection the diphtheria bacillus is often present. This 
membrane is easily separated from the underlying mucous membrane, 
and is made up largely of clotted fibrin and cells. The diphtheritic false 
membrane of diphtheria more rarely extends to the larynx or the nose, 
and is intimately attached to and forms a part of the inflamed mucous 
membrane, attempts at removal resulting in the tearing of superficial 
portions of the mucous membrane. In severe but not fatal cases healing 
is attended with ulceration and scars. Microscopical examination shows 
that the diphtheritic false membrane also is composed of a net- work of 
clotted fibrin, but it is intimately connected with the mucous membrane, 
in which there is a fibrino- cellular infiltration, and its superficial portions 
are necrotic. 

In the gangrenous condition following diphtheritic inflammation, the 
putrid sore throat of earlier writers, the necrotic tissue becomes infected 
with other bacteria, and putrefaction results. Hemorrhages are frequent 
in gangrenous diphtheria, and sloughing of the tonsils and of the palate 
may occur. 

The pharyngeal inflammation may extend into the Eustachian tubes, 
while its continuance is frequent into the larynx, trachea, and bronchi. 
Above the vocal cords the false membrane is intimately adherent to the 
mucous membrane, but below these cords it is generally but loosely 
attached, and often lies upon the inflamed mucous membrane. In the 
trachea it is apt to form a hollow cylindrical cast of this tube. The same 
is true of the larger bronchi, while its extension into the smaller bronchi 
is generally in the form of solid cylinders. The lungs are usually dis- 
tended, injected, and contain numerous patches of lobular atelectasis and 
nodules of broncho- pneumonia. If stenosis of the larynx occurs, emphy- 
sema of the lung, either intra- or extra-alveolar, is likely to be found. 



INFECTIOUS DISEASES. 



167 



The lymphatic glands beneath and behind the lower jaw are enlarged, 
soft, and on section of a reddish-gray color. Pericardial and pleural ecchy- 
moses are frequent. The heart is of an opaque gray or grayish-yellow 
color, and the muscular fibres may show extensive fatty degeneration. 
Acute endocarditis sometimes, though rarely, occurs. The spleen is en- 
larged, its consistency diminished, and on section the pulp is increased 
and of a reddish-gray color. The kidneys are enlarged, the capsule read- 
ily detached, the surface at times speckled with extravasated blood. On 
section the cortex is swollen, the region of the convoluted tubes opaque. 
On microscopic examination the epithelium may be found necrotic or 
in a state of fatty degeneration, Bowman's capsules thickened, and the 
nuclei in the glomeruli increased. Hyaline casts are to be found in the 
tubes. The liver shows the appearances characteristic of a parenchyma- 
tous degeneration. Diphtheritic patches are sometimes to be found upon 
the lips, tongue, cheeks, oesophagus, and stomach. The solitary follicles 
and Peyer's patches in the small intestine are swollen, and the mesenteric 
lymph-glands enlarged and injected. The brain may contain spots of 
red softening, probably due to embolism, and the lesions characteristic 
of a neuritis have been found in the peripheral nerves. Among the rarer 
complications are descending retropharyngeal abscesses involving the 
tissues around the oesophagus and in the anterior mediastinum, abscesses 
of the lung, suppurative pleurisy, pericarditis, and arthritis. Diphthe- 
ritic inflammation of the conjunctiva, vulva, and vagina, and of wounded 
surfaces, especially in case of tracheotomy, are sometimes found. 

Frosch and others, most recently Wright and Stokes, have sought for 
the diphtheria bacillus in other parts of the body than the inflamed 
throat. It has been found extensively, but only in small numbers, it 
being necessary to use comparatively large portions of the parenchyma 
and blood upon the culture media to secure a growth. It has been in 
this way obtained from the lungs, liver, spleen, brain, and bronchial and 
cervical lymph-glands, and from the blood from the heart. The toxin 
of the diphtheria bacillus is considered to be especially destructive to 
cell-life, and the necrosis of cells in remote parts of the body, as well as 
of those in the inflamed pharyngeal mucous membrane, is regarded as 
the effect of this toxin. The combined effect of the diphtheria bacillus 
and of associated cocci is especially dangerous. Disturbances due to the 
diphtheria bacillus are instituted in the place of its growth, while those 
from other organisms, especially the streptococcus and the staphylo- 
coccus, result from their invasion of the interior of the body by means 
of the lymphatics and the blood-vessels or air-passages. 

In the false membranes of diphtheria streptococci may also be present 
in combination with the diphtheria bacillus. Especial importance is to 
be attached to the presence of the former in explanation of some of the 
severe complications of diphtheria, and in accounting for the unfavor- 
able results from the use of antitoxin. This agent, it is asserted, though 



168 



GEXERAL DISEASES. 



capable of neutralizing diplitherial toxins, is not known to oppose the 
action of pyogenic cocci. 

Symptomatology. — The symptoms of diphtheria may arise in the 
course of two days or more after exposure. The earliest symptoms are 
usually fever and pain in swallowing. The fever may be preceded by a 
chill or chilliness. The temperature rises from 102° to 104° F., and the 
dysphagia may be slight or considerable. The higher the fever the more 
probable the occurrence of headache, backache, loss of appetite, and 
weakness. The examination of the throat may show no other change 
than the redness and swelling of inflamed tonsils and pharyngitis. The 
especial feature suggestive of diphtheria is the formation of a false 
membrane. This appears first as grayish- white spots or patches, often 
formed in the course of a few hours and rapidly increasing in size. It 
is to be remembered that diphtherial patches may be present on the 
upper surface of the soft palate, or in the pharyngeal pouches, hence 
invisible without a mirror, and the case be one of diphtheria. As the 
disease progresses, the spots and patches coalesce, and extend to the soft 
palate and the uvula, and in persons with large tonsils, especially children, 
the voice becomes thick, the lymph-glands behind the jaw moderately 
swollen and sensitive, especially on the side corresponding to that show- 
ing the more advanced inflammatory changes, and the urine is likely to 
contain a small or large trace of albumin. The attack may be mild or 
severe, a change from one variety to the other often taking place unex- 
pectedly. In mild diphtheria there is but little general disturbance. 
The appetite may remain good, prostration slight, the fever quickly dis- 
appear, the membranes become thinner and smaller, thus fading away, 
and in less than a week the patient be well. 

The severe cases of diphtheria are characterized by conspicuous 
septic symptoms. The severity of the attack may be evident from the 
first, or the graver symptoms may develop in a few days in apparently 
mild cases. The temperature may be high, 104° F., at the outset, or, as 
graphically shown by Heubner, rise on the third or fourth day. It may, 
however, be only moderately elevated, or even subnormal. The pulse is 
rapid and weak, corresponding to the range of temperature. The patient 
may be delirious, but usually is in a condition of indifference or is 
drowsy. There is no appetite. Vomiting and diarrhoea are frequent. 
The breathing is slow, perhaps rapid and noisy, and the voice is hoarse. 
A thin red or yellow acrid discharge flows from the nostrils, producing 
sores or crusts upon the lips. The mouth is usually open, the tongue 
dry and fissured. The false membrane is found throughout the pharynx 
either diffused or in patches, and forms a thick opaque yellow crust re- 
sembling wash-leather. In the gangrenous cases the pseudo- membranous 
patches become green or brown, are moist and shreddy, and of a very 
offensive odor. Hemorrhages are frequent and sometimes considerable 
from the mouth and nose, and may also occur in the skin. The glandular 



INFECTIOUS DISEASES. 



169 



swellings behind and under the jaw become greatly increased, and the 
resulting deformity is enhanced by oedema of the surrounding fibrous 
tissue. There is marked albuminuria, and hyaline casts are present. 

Severe cases of diphtheria progress on the one hand with suffoca- 
tive symptoms, on the other with those of septicaemia. Mild cases of 
diphtheria may be attended with suffocative symptoms, and a fibrinous 
laryngitis may be the sole significant lesion in diphtheria, diphtherial 
croup, or laryngeal diphtheria, the Klebs-Loeffler bacillus being found in 
the pharynx. Croupous symptoms may develop suddenly or gradually. 
The respiration becomes more noisy and labored. A frequent dry bark- 
ing cough is present. Paroxysms of dyspnoea may occur and the face 
become purple, relief being brought about by the expulsion of pieces 
of fibrinous membrane from the larynx or trachea. If relief is not 
obtained, the patient becomes anxious, the skin pale and moist, the 
extremities cool, the pulse weak, and death occurs sometimes from acute 
suffocation, sometimes from prolonged asphyxia. The latter condition 
prevails in those cases in which the fibrinous inflammation extends into 
the bronchi. When the symptoms of septicaemia are prominent, the 
prostration of the patient is extreme, and swallowing is difficult, largely 
due to paralysis of the soft palate, perhaps necessitating the use of the 
stomach-tube. The pulse is weak and irregular, and the heart-sounds 
are faintly heard. Death may occur suddenly and unexpectedly from 
cardiac paralysis even during apparent convalescence. 

Complications. — The complications occurring in diphtheria are both 
early and late, and are especially met with in the severe cases. The 
early complications consist in extension of the pharyngeal inflammation 
to the middle ear and of the fibrinous inflammation to the air-passages, 
and the production of broncho-pneumonic nodules by the inhalation of 
food and of bits of membrane. Abscesses of the lung and pleurisy may 
occur. Eetropharyngeal, pericesophageal, and mediastinal abscesses may 
result from infection from the throat. Serous or purulent inflammation 
of the joints is at times found. Such lesions are usually indicated by 
an elevation of temperature in addition to localizing symptoms, as pain 
or swelling. Most important of the late complications is paralysis, the 
result of a peripheral neuritis, which generally occurs about the third 
week after the acute symptoms of the disease. The soft palate is oftenest 
affected, then the muscles of the eye, especially those of accommoda- 
tion, and less frequently the muscles of the larynx, trunk, and extremi- 
ties, and the diaphragm. The muscular paralysis may occur in cases 
of diphtheria so mild as not to excite suspicion of this disease. The 
affection of the palate is indicated by a nasal voice and the escape of 
liquid from the nose during attempts to swallow. Strabismus or weak- 
ened eyesight gives evidence of the ocular paralysis. Aphonia, or a 
hoarse or whispering voice, indicates the affection of the vocal cords, 
while inability to sit upright or to support the head indicates paralysis 



170 GENERAL DISEASES. 

of the muscles of the trunk, and an ataxic gait and absent patellar 
reflexes give evidence of the affection of the nerves of the legs. Adolf 
Baginsky calls especial attention to the importance of recognizing paral- 
ysis of the diaphragm, which is indicated by dyspnoea, a sunken abdo- 
men, and suffocative attacks. The sensitive nerves also may be affected 
in consequence of a neuritis. Severe cerebral symptoms, as spasms, 
hemiplegia, and coma, may be due to diphtheria, and when occurring 
are to be regarded as the result of a focal encephalitis of embolic origin. 
The nephritis present as a late complication of diphtheria is represented 
by the persistence of the albuminuria and casts, but is usually insufficient 
to produce ursemic symptoms or dropsy, speedy recovery being the rule. 

A rare manifestation of diphtheria is membranous or fibrinous rhi- 
nitis. It is characterized by the presence of an opaque white membrane 
upon the mucous membrane of the nostrils, as a rule associated with but 
little symptomatic disturbance except anaemia and debility, but often 
persisting for weeks or months. Abbott and others have found virulent 
diphtheria bacilli present in the membrane, and some, if not all, of such 
cases are to be regarded as nasal diphtheria, dangerous to others, if not 
harmful to the patient. 

Diagnosis. — The diagnosis of diphtheria ultimately depends upon 
the discovery of the Klebs-Loeffler bacillus in a case of sore throat. 
Its presence should be suspected until disproved in cases of apparently 
simple catarrhal tonsillitis or pharyngitis during the occurrence of epi- 
demics of diphtheria, and especially after known exposure to a case of 
diphtheria. According to Heubner, it is impossible in certain cases of 
diphtheria to make a positive diagnosis in the first two or three days 
without a bacteriological examination. All cases of membranous sore 
throat, whether appearing as lacunar tonsillitis, fibrinous or diphtheritic 
tonsillitis, or pharyngitis, are to be regarded as diphtheria until the bac- 
teriological examination has denied the presence of the specific bacillus. 
Cases of fibrinous laryngitis, so-called croup, are usually of diphtherial 
origin even in the absence of pharyngeal symptoms, and should be 
regarded as laryngeal diphtheria unless directly attributable to the in- 
halation or application of irritants or unless bacteriological examination 
has shown the absence of the diphtheria bacillus. Cases of membranous 
rhinitis are to be regarded as nasal diphtheria unless the absence of 
the Klebs-Loeffler bacillus has been demonstrated. A diphtheritic con- 
junctivitis and a diphtheritic inflammation of wounds should lead to a 
search for the diphtheria bacilli : their presence in such cases would 
demand the isolation of the patient, that others might not incur the risk 
of infection. The .appearance of a false membrane is insufficient for the 
absolute diagnosis of diphtheria. A pseudo -membranous inflammation 
of the throat, including the tonsils, soft palate, and uvula, may occur in 
scarlet fever, measles, typhoid fever, and in other infectious diseases. 
The membrane may present no physical characteristics by means of 



INFECTIOUS DISEASES. 



171 



which it is to be distinguished from that occurring in diphtheria. The 
bacteriological examination in such cases shows the presence of strep- 
tococci, perhaps of staphylococci and other bacteria, but no diphtheria 
bacillus. To such a condition the term pseudo-diphtheria or diphtheroid 
has been applied. Morse examined four hundred cases of inflammation 
of the throat occurring in diphtheria and scarlet fever and found the 
Klebs-Loeffler bacillus present in sixty per cent, of the cases. Welch 
states that in his experience in not more than five per cent, of the cases 
in which the clinical diagnosis of diphtheria was well established were 
the Klebs-Loeffler bacilli lacking. Of five hundred and fifty-eight cases 
examined by Heubner in -which the presence of bacilli was suspected in 
virtue of the stage and course of the disease and the localization of the 
exudation, in only seven were they not found. 

The diphtheritic pharyngitis in scarlet fever most closely resembles 
that occurring in diphtheria. The fever is higher and more continuous. 
The degree of swelling is greater, the extension to the Eustachian tube 
is more constant, and the characteristic eruption of this disease soon 
makes its appearance. The possibility that the diphtheria bacillus may 
be present in the scarlatinal sore throat may be considered, but Booker 
examined bacteriologically the secretions from the throat in twenty-three 
cases of scarlet fever and found streptococci in all, the diphtheria bacillus 
being absent. Park found that most cases of false membrane limited to 
the tonsils of adults were not diphtheria, that most cases of acute pharyn- 
gitis with little or no membranous exudation were not diphtheria, and 
that the majority of uncomplicated cases of membranous laryngitis were 
diphtheria. In young children the tonsillitis accompanied with exuda- 
tion limited to the crypts or extending beyond them, whether there was 
much or little false membrane, might or might not be due to diphtheria. 
He also found in the milder cases of membranous pharyngitis as a charac- 
teristic of diphtheria irregular patches of adherent false membrane on the 
tonsils or margins of the faucial pillars. 

For the recognition of the Klebs-Loeffler bacillus special training in 
bacteriological methods is obviously necessary. The importance of 
making cultures especially from doubtful or suspicious cases of sore 
throat is such that laboratories for this purpose are rapidly becoming 
established at accessible points in various parts of the country. The 
larger cities and towns offer gratis the necessary facilities. Test-tubes 
containing the culture medium, carefully packed in metal boxes which 
carry the necessary directions, are to be had at various centres of dis- 
tribution. 

Prognosis. — The mortality from diphtheria varies within wide limits 
during successive years and in different localities in the same year. The 
statistics of such mortality are only of relative value, owing to the diffi- 
culties inherent in the satisfactory classification of the cases under con- 
sideration. In a recent communication by Welch on the treatment of 



172 



GENERAL DISEASES. 



diphtheria by antitoxin, it is stated that the mortality at the surgical 
clinic in Berlin during ten years varied between 58.5 and 43.2 per cent. 
In the London hospitals the variation in certain years was between 29.3 
and 40.7 per cent. Of seven thousand one hundred and sixty-six patients 
recently tabulated by Welch as having been treated with antitoxin, the 
mortality was 17.3 per cent. Mason states that in Boston the mortality 
from diphtheria from January to May, 1895, during the use of antitoxin, 
was 14 per cent., against 31 per cent, in the previous year. According 
to Heubner, in 1894 the mortality in thirteen hundred and thirty-two 
patients with diphtheria in the Berlin hospitals was 38.8 per cent., while 
of fifteen hundred and thirty-four cases treated with antitoxin the mor- 
tality was 19 per cent. Baginsky between March 15, 1894, and March 15, 
1895, treated five hundred and five children with antitoxin, with a mor- 
tality of 15.6 per cent. In August and September antitoxin was not used, 
and one hundred and twenty-six children were treated, with a mortality 
of 48.4 per cent. 

The prognosis in any case of diphtheria is always doubtful, since the 
mildest cases may become severe and the severe cases may improve. 
The prognosis is especially grave among children and in proportion to 
their youth ; sucklings, however, are rarely affected. The prognosis is 
more severe among patients debilitated by previous disease or faulty 
hygienic surroundings. The outlook in the individual case is worse as 
the disease becomes septic or gangrenous, since a mixed infection then 
exists. Convalescence from the mild cases of diphtheria usually occurs 
towards the end of a week, while in septic cases the disease may con- 
tinue for a period of two or three weeks. Gangrenous diphtheria is 
usually fatal in the course of a week. The range of temperature is less 
indicative of the degree of toxaemia than are the extreme prostration, 
swelling of the lymphatic glands, offensive discharge from the mouth 
and nostrils, and abundant albuminuria. The prognosis becomes grave 
when there is extension of the inflammatory process to the larynx and 
lungs, or when the action of the heart becomes weak and irregular. It 
is to be remembered that patients, especially children, may suddenly die 
from cardiac paralysis, generally due to extensive fatty degeneration of 
the heart, even weeks after apparent convalescence. Nephritis is rarely 
sufficient to serve as a cause of death, the symptoms of this complication 
ordinarily disappearing in the course of a few or several weeks after re- 
covery from the acute symptoms of the disease. Diphtheritic paralyses 
are usually recovered from unless respiration and circulation are conspic- 
uously affected, and especially when there is paralysis of the diaphragm. 

Treatment. — In the treatment of diphtheria it is desirable that the 
patient be thoroughly isolated in a room from which have been removed 
carpets, unnecessary furniture, and other articles capable of acting as 
fomites. The utmost care should be exercised to see that the urine, the 
faeces, and especially all discharges from the mouth and nose are at once 



INFECTIOUS DISEASES. 



173 



thoroughly disinfected. (See Typhoid Fever. ) The room should he well 
ventilated, and kept at a temperature of about 70° F., with the air thor- 
oughly moistened by means of a steam atomizer, boiling tea-kettle, or other 
device. The inhalation of balsamic vapor is thought by many to be use- 
ful, and we have ourselves apparently gained advantage by heavily im- 
pregnating the air about the child with the oil of eucalyptus, diffused by 
means of the steam atomizer or by simple boiling. No one should enter 
the room except the nurses and the medical attendants, who should take 
the greatest care to avoid personal infection from the discharges and also 
the infection of others by carrying the poison upon their clothing. Thus, 
the doctor should put on a linen duster, apron, or other similar garment 
whenever he comes to the patient. Deaths have occurred among doctors 
and nurses from lodgement of a piece of infected mucus in the eye or 
upon some abrasion during the local treatment. 

The tendency of the disease is usually towards exhaustion. The child 
should be kept as quiet as possible, and during early convalescence 
should not be too much encouraged to play with toys. Whenever there 
are signs of cardiac failure the horizontal position should be rigidly en- 
forced. The strength should be sustained by feeding at intervals of 
from three to five hours with nutritious, easily digested food, in as large 
quantities as can be borne. Owing to the difficulty of swallowing, milk, 
eggs, soups thickened by stirring in them ordinary mashed potatoes, 
tapioca, sago, or other starchy materials, milk toast, and other liquid or 
semi-liquid foods, must be chiefly relied upon ; but sweetbreads, birds, 
and similar food should be used on occasion. The tendency not only 
to exhaustion, but also to depression, is always so great that alcoholic 
stimulants should usually be exhibited from the beginning of an attack. 
At first they should be given with the food and in moderate doses ; in 
the latter stage of the disease they should be exhibited with the greatest 
freedom both with the food and at other times. 

The objects of the local treatment of diphtheria are the controlling 
of the inflammatory action of the throat, the cleaning out of debris and 
material capable by its putrefaction of producing poisonous substances, 
the removal of the membrane, and the destruction of the diphtherial 
organism. Experience has shown that the only way of controlling the 
inflammatory action of the throat is to destroy the cause of that action, 
— namely, the bacillus : so that at present the attempt to subdue in- 
flammation is reduced to the use of ice, or more rarely of hot applica- 
tions, which, at least, often serve to relieve discomfort. The ice should be 
continuously applied, by means of especially prepared india-rubber bags, 
Leiter's tubes, or other receptacles, to the swollen glands and tonsillary 
region, whilst the patient should be encouraged in the free use of cracked 
ice, for which often may be substituted with advantage frozen milk, ice- 
cream, frozen beef-essence, frozen chicken jelly, or other frozen foods. 

For the cleaning out of the debris of the throat or nose salt water 



174 



GENERAL DISEASES. 



may be used, but certain solutions are preferable. Among these the most 
important is the official solution of dioxide of hydrogen, which may be 
applied (from twenty-five to fifty per cent. ) every three or four hours to 
the pharynx by means of the mop, or may be used diluted with four or 
five times its bulk of water by the atomizer. It is capable of irritating 
and even causing ulceration of the mucous membrane, but in our ex- 
perience we have never seen it do harm. If it seem too strong for any 
individual throat, it should be further diluted. When it causes irri- 
tation, atomization with a saturated solution of boric acid with thymol 
(gr. ii to f |i) often soothes the throat. 

In nasal diphtheria it is especially important that the passages be 
thoroughly cleansed, and, if possible, disinfected, at short intervals. 
Lime water, simple solutions of salt, the one per cent, solution of car- 
bolic acid, saturated solution of boric acid, and diluted Loeffler's solution 
have been variously recommended by authorities. We have used ten 
per* cent, solution of sodium sulphite with satisfaction. In adults or 
children the nostrils may be cleaned out by throwing the spray of an 
atomizing syringe into the posterior nares through the throat. Usually 
the better way is to introduce the nozzle of an atomizing syringe hori- 
zontally into the external nostril and to give the injection with such 
freedom and force that, if it be possible, it shall work its passage through 
the other nostril. 

Two methods of destroying the membrane are conceivable. One is by 
astringent substances which shall cause such coagulation and shrinkage as 
to bring about removal ; the other is by solvents. Early in the attack 
some practitioners use a very strong solution of silver nitrate. Various 
preparations of iron have a tendency to shrivel the mucous membrane, 
and are also germicidal. They have been much used. Perchloride of 
iron has been especially employed in various forms. We have often used 
Monsel's solution as equally efficient and less irritant than the chloride. 
As solvents of the false membrane, animal ferments, such as pepsin and 
trypsin, and vegetable ferments, such as papain, have been very highly 
commended from time to time. They are entirely safe, produce little 
or no irritation, and are therefore harmless, but their effectiveness is a 
matter of great doubt. Lime water has been much used ; but probably 
the most powerful available solvent of false membrane is lactic acid. 
Lennox Browne highly recommends the application of the pure acid to 
the throat by means of a dense swab of absorbent cotton with sufficient 
firmness to detach the membrane at its edge. The usefulness of both 
astringents and solvents is much limited by the fact that complete de- 
struction of the false membrane (were it possible) would not affect the 
bacillus in the underlying mucous membrane. 

Various germicides have been used, in the hope of destroying the 
bacillus. In the first stages of the disease the small spots of membrane 
may be carefully touched with a concentrated carbolic acid ; later, glyce- 



INFECTIOUS DISEASES. 



175 



rin containing from three to five per cent, of carbolic acid may be used 
upon large, diffused surfaces. Loeffler's solution, composed of ten grammes 
of menthol diluted in thirty-six cubic centimetres of toluol and added to 
four cubic centimetres of liquor ferri sesquichlorati (Br. Ph.) and sixty 
cubic centimetres of absolute alcohol, has been much used abroad, ap- 
plied in full strength by the swab or diluted by atomization. Corrosive 
sublimate, one part to one thousand, is employed by some practitioners. 
The biniodide of mercury is preferred by others because it does not pre- 
cipitate serum albumin, and is, therefore, more apt to penetrate the mem- 
brane : it is also less apt to undergo decomposition. Mercurial prepara- 
tions should be applied by means of an atomizer of some sort, and a 
known quantity of the mercurial should be thrown into the throat, so as 
to avoid any possibility of giving too much of it, especially when calomel 
or corrosive sublimate is being given for its general effect. 

The result of our own experience in diphtheria has led us to believe 
that the thorough cleansing of the throat at short intervals with dioxide 
of hydrogen is a very valuable part of the treatment, and that, though 
such use may be followed by a more pronouncedly germicidal application, 
the latter is of doubtful value, especially if mercurials are being em- 
ployed internally. If calomel be administered in a dry powder, or cor- 
rosive sublimate in a not too dilute solution, it diffuses over the throat 
before entering the stomach, so that whatever local action it is possible 
to get from the mercurial is obtained. This also applies to the iron 
preparations. 

There is no known specific drug in diphtheria. Potassium chlorate 
has no control over the disease, and in no way supports or increases the 
resistive power of the system. It is largely eliminated by the saliva, 
and when taken internally exerts a continuous influence upon the dis- 
eased parts, but is not sufficiently bactericidal to be of value. When 
given in large doses it very greatly increases the danger to life by its 
action upon the kidneys, which is parallel with that of the disease. If 
it be used it should therefore be given in dry powder in very small 
doses. We do not think that tincture of chloride of iron can be con- 
sidered as having any influence upon the bacillus of the disease or upon 
the products which it forms in the blood ; it would seem, however, 
to be indicated by the rapid destruction of the red blood-corpuscles, 
which is a part of the diphtherial process ; and its influence upon the 
kidneys is beneficial. Its use is also sanctioned by a wide-spread belief 
in the profession that it is of value. If used at all, it should be given 
with glycerin and water at short intervals in such dosas as the stomach 
will easily bear. During the last few years the mercurials have been very 
largely employed in the treatment of diphtheria. Some practitioners 
\ prefer the corrosive chloride ; others vaunt the value of calomel and soda 
rubbed together $ others prefer simple calomel. It probably makes very 
little difference which one of these preparations is selected. We have 



176 



GENERAL, DISEASES. 



been accustomed to use calomel, which, for the reason already stated, 
should be given in dry powder. In the beginning of an attack from one- 
quarter to one-half grain may be administered every two hours until free 
purgation is produced, and when the constitutional depression is not great 
the very free administration of the drug late in the disorder seems, at 
times, to aid in loosening the false membrane. If corrosive sublimate 
be preferred, one seventy-second of a grain may be given every two hours 
at two years of age ; at six years of age one-fortieth of a grain ; at ten 
years of age one-thirtieth of a grain. Many practitioners, however, employ 
much larger doses than this ; Jacobi recommends half a grain of the bi- 
chloride during the day for an infant one year old. 

Pilocarpine has been employed to a considerable extent for the purpose 
of causing free secretion in the mouth and throat and thereby loosening 
the membrane. Its action for good is, however, very uncertain, and it 
may greatly increase the danger by provoking so much secretion into the 
bronchial tubes as to interfere with respiration. 

As stimulants in diphtheria, alcohol, strychnine, digitalis, and stro- 
phanthus are often of great value. 

Sometimes in diphtheria dangerous nasal hemorrhage occurs. It can 
often be controlled by pushing up the nostril a small roll of absorbent cot- 
ton saturated with a fifty per cent, dilution of the official solution of diox- 
ide of hydrogen, or by astringent injections, but may necessitate plugging. 

When the temperature reaches 102° F. in diphtheria the patient 
should be well sponged with cold water. If this fail to reduce the fever 
the cold pack or bath should be employed. The temperature of the bath 
should be started at about 90° F. and reduced as low as 70° F. if neces- 
sary. It is important, however, that the treatment be no more severe 
than is absolutely required for the reduction of the temperature, and 
when the thermometer in the rectum or in the mouth indicates 100.5° F. 
the patient should be taken out of the bath. In feeble cases it may be 
wise to apply the hot-water bag to the feet during the bath. 

When in a case of diphtheria cyanosis and restless insomnia are 
combined with evident labored breathing and marked retraction of the 
lower ribs and at the supraclavicular spaces and the suprasternal notch, 
either intubation or tracheotomy becomes necessary. According to the 
statistics of Henry E. Wharton, intubation gives better results than 
tracheotomy in children under two years of age ; after this the results are 
about the same. (For the method of performing these operations the 
reader is referred to works upon surgery.) 

Feeding by means of a tube may be necessary during the acute stage 
in consequence of the dysphagia resulting from pharyngeal pain and 
obstruction. A soft rubber catheter passed through the nose may then 
be found more convenient than the stomach-tube introduced through the 
mouth. In the stage of paralysis the stomach-tube may be required to 
prevent regurgitation of food through the mouth or nostrils. 



INFECTIOUS DISEASES. 



177 



Antitoxin Treatment — In 1890 Behring and Kitasato published their 
first article upon the use of the blood serum of artificially immunized 
animals in the treatment of diphtheria. After the third publication in 
1892 the subject attracted wide-spread attention, and became a matter of 
clinical investigation by Roux and others. 

It has been demonstrated that in the lower animals diphtheria can 
be cured with antitoxin. How the antitoxin acts still remains uncer- 
tain, but the probabilities favor the theory that it influences the living 
body in such a way as to render the cells tolerant of the toxin. Never- 
theless, the chemical theory that the antitoxin directly neutralizes the 
toxin still has advocates. The antitoxin has no direct bactericidal effect, 
although it arrests the spread of the local inflammation and the growth 
of the bacillus, probably by preventing the tissues from being so poi- 
soned by the toxin that they are unable to resist the bacillus. It is 
proved that it requires a definite quantity of the antitoxin to neutralize 
the effects of a definite quantity of toxin. 

In using antitoxin in human medicine it is, of course, impossible to 
know how much toxin is present in the individual patient. The dose 
of the antitoxin is, therefore, always uncertain and empirical : the older 
the patient, the longer the duration and the greater the intensity of the 
disease, the larger the dose required. Certain untoward effects may 
follow its use 5 rarely a local abscess is formed, but diffused erythema, 
rheumatoid swelling of the joints, general urticaria, and albuminuria 
have been noticed in a number of cases, — effects sufficiently serious to 
make it wise to repeat the small or moderate dose of antitoxin, if neces- 
sary, rather than in the beginning to give an overwhelming amount. 

Anti- diphtheric serum may be of various strengths, but the unit of 
dose generally received is that inaugurated by Behring : this unit is one 
cubic centimetre of the so-called normal serum, which is of such strength 
that one cubic centimetre will overcome ten times the minimum dose 
of diphtheric poison fatal to a guinea-pig. The ordinary dose of the 
serum, which should be injected into the buttock or flank, is sixty anti- 
toxin units. If by the next day there has been no marked improvement, 
one hundred units may be given. In very severe cases, or when the 
patient is not seen until late in the disorder, from one hundred to one 
hundred and forty units may be administered at the first dose. In suc- 
cessful cases the effects of the serum are apparent within a few hours 
in the subsidence of the fever, the slowing of the pulse, and the reduc- 
tion in the severity of the local symptoms. Inside of twenty-four hours 
the membrane should begin to disappear. 

Although the exact power of the antitoxin treatment can hardly be 
considered to be determined, yet certainly its value lias been so far proved 
that it should be used in every case of diphtheria with as much positive- 
ness and determination as quinine would be employed in malaria. In 
the statistics collected by Welch, embracing many thousands of cases, 

12 



178 



GENERAL DISEASES. 



the mortality was reduced by the use of antitoxin about half. In the 
Paris hospitals, from 1880 to 1889, the yearly average of deaths from 
diphtheria was 1840. In 1890 there were 1668 deaths ; in 1891, 1361 ; in 
1892, 1403 ; in 1893, 1266 ; in 1894, 1009 ; and in 1895, 435. The total 
death-rate thus fell after the introduction of the serum treatment to about 
one- fourth of what it had been for many years, and to one- third of the 
average for the previous five years. Nevertheless, it is certain that the 
serum treatment frequently fails. Some of the reasons for such failure 
are, however, obvious. In the first place, antitoxin cannot remedy damage 
already done to organic cells and tissues, so that an injection late in the 
disease, though it may put an end to the diphtherial process, may not 
prevent death. In the second place, in most serious cases there are two 
infections, a primary one, — that with the diphtherial organism, — and a 
secondary one, — that with various streptococci and other pathogenic 
germs which follow upon the diphtheria. An antitoxin treatment may 
put an end to the first infection, but death may result from the second- 
ary infection, over which the antitoxin has no direct influence. 

It is evident that the earlier the treatment with antitoxin the greater 
the chances of recovery. Very few fatal cases are on record in which 
death has occurred when antitoxin was properly administered during the 
positively determined first day of the disease. In eight hundred and 
fourteen cases reported collected by Welch, in which treatment was begun 
before the third day, only a very little over five per cent, ended in death. 
Indeed, it would seem from these statistics that when the serum treatment 
is begun on the third or fourth day the mortality is thirty-six per cent, 
greater than in cases treated on the first or second day, and three and a 
quarter times less than in cases treated after the fourth day. In our 
opinion, the practitioner should at once begin the antitoxin treatment 
whenever the clinical features of the case warrant the diagnosis of diph- 
theria, without waiting for the confirmation of this diagnosis by bac- 
teriological methods. 

There is no reason for believing that the antitoxin has any direct 
sedative influence upon the heart or irritative influence upon the kidneys, 
and certainly by arresting the diphtherial process it has great tendency 
to prevent complications and secondary effects. In laryngeal diphtheria 
with stenosis, requiring operation, there is sufficient accumulated experi- 
ence to show that the serum is a very valuable agent in preventing the 
progressive development of the false membrane in the small tubes, and 
that in many cases in which intubation would be otherwise insufficient 
the antitoxin treatment does away with the necessity of tracheotomy. 

The value of antitoxin as an immunizing agent has not been clin- 
ically determined, although guinea-pigs may be rendered completely im- 
mune. One attack of diphtheria does not protect from a second, and 
it therefore seems incredible that a permanent immunity can be obtained 
in any artificial way. The exact immunizing dose has not been agreed 



INFECTIOUS DISEASES. 



179 



upon : Behring considers it to be two hundred antitoxin normals, but 
Bosenthal affirms that half this quantity is sufficient when the expo- 
sure is simply that of coming into the neighborhood of the infection. 
Behring directs that the dose be repeated in eight weeks. Whilst there 
is so much doubt concerning immunization, it seems to us that the better 
plan is to watch exposed cases and inject the serum when the first symp- 
toms of the disease appear. 

WHOOPING-COUGH. 

Definition. — A contagious disease, especially attacking children, 
characterized by violent paroxysms of coughing, with spasm of the glottis, 
and respiratory catarrh. 

Etiology. — Whooping-cough is endemic in most large cities, but 
occurs especially in epidemics, in which it probably spreads by con- 
tagion from child to child. The exact nature of the poison is not en- 
tirely determined. Letzerich asserts that he was able to produce the 
disease in animals by insertion of the sputum into the trachea, and 
believes the germ to be a micrococcus. Deichler affirms that it is an 
amoeboid protozoon. According to Afanassiew, it is a short bacillus 
(bacillus tussis convulsivce), pure cultures of which, when applied locally, 
cause in the lower animals respiratory catarrh. The fact that occasional 
cases have been reported in which the disease was congenital would 
indicate that the poison, whatever its nature may be, is capable of 
causing the affection by inoculation, and that therefore whooping-cough 
is not necessarily primarily a disease of the respiratory tract, due to the 
local presence of an organism ; although it is probable that in whooping- 
cough, as in diphtheria, the germ usually first finds a local lodgement. 
Subjects who are especially liable to pulmonary catarrhs are certainly 
very susceptible to the whooping-cough poison, but of all predisposing 
causes youth seems to be the most active. Whilst the disease is rare 
in infants under six months, more than half the cases occur in children 
under four years of age, and attacks are common up to six, but rare after 
ten, and exceedingly rare in adults, although sometimes occurring in old 
age. Eecurrences are occasional. The wide-spread belief that the dis- 
ease is more frequent in girls than in boys is of doubtful correctness. 

Morbid Anatomy. — The characteristic change in whooping-cough 
consists of a catarrhal inflammation of the respiratory mucous membrane, 
which, according to the studies of Meyer-Huni and Yon Herff, is most 
severe in the nose, larynx, and trachea, although it may extend into the 
small tubes. The so-called cough region, which is supplied by the sen- 
sitive filaments of the superior laryngeal nerve, — namely, the posterior 
wall of the interarytenoid region, — seems in most cases to be the chief 
focus of disease. The most frequent secondary lesions are capillary 
bronchitis and pneumonia. Enlargement of the tracheal and bronchial 
glands is so common that the theory has been supported by able clinical 



180 



GENERAL DISEASES. 



pathologists that the disease is essentially a bronchial adenopathy. This 
certainly is not correct, and it is probable that the frequency of these 
glandular enlargements at post-mortems depends upon the excessive 
fatality of whooping-cough in strumous children. Although albuminuria 
is frequent, severe nephritis is very rare. 

Symptomatology. — The period of incubation in whooping-cough is 
usually from three to four days, but it may be as short as forty-eight hours, 
or may extend beyond the week. In accordance with general custom, 
three stages of the disease may be recognized, if it be understood that 
these stages are artificial divisions and pass insensibly one into the other. 
The first or catarrhal stage usually comes on insidiously. In the begin- 
ning the symptoms are those of an ordinary cold, but in a short time a 
distinct tendency to nocturnal exacerbations and to paroxysmal coughing 
may be noticed. Suspicion also should be aroused by the fact that the 
cough is much more severe than would seem to be called for by the very 
slight physical signs presented, and by the absence of distinct disorder 
of voice. Fever is often wanting, and when present consists chiefly in a 
rise of temperature towards evening. If, however, a pulmonary catarrh 
develop, the fever may be severe. The stage lasts in most cases about 
two weeks. Sometimes it may be shortened to three days or even less. 
More frequently it is prolonged even up to six weeks. As a rule, the 
younger the child the shorter the catarrhal stage. 

As the second stage is reached the coughing becomes more purely 
paroxysmal, and finally is attended with the distinctive "whoop." In a 
violent paroxysm, the child, moved by a warning sensation, ceases its 
play, runs to its care-taker or catches hold of some object for support, and 
is immediately seized with a series of short, rapidly repeated, explosive, 
expiratory coughs, without any respiration between them, and with an 
increasing turgidity and cyanosis of the face, which may continue until 
the whole countenance is dark and swollen, with prominent eyeballs, 
protruding mouth, watery eyes, and seemingly imminent suffocation. 
Then the spasmodically closed glottis partially relaxes, and a deep inspi- 
ration occurs, accompanied by a loud crowing or whooping sound. This 
may be followed by a return of the cough, with the whoop at the end of 
it. In very severe cases subconjunctival, nasal, or even tracheal hemor- 
rhage may occur, and involuntary urination or defecation occasionally 
happens. Very frequently the paroxysm is cut short by violent vomit- 
ing, attended with a free expulsion of ropy mucus from the respiratory 
tract, and when severe it may be followed by complete exhaustion. The 
paroxysms vary in frequency as they do in intensity. There may be six 
or there may be eighty in the twenty-four hours. They are always much 
more severe and frequent at night, and are liable to be excited by singing, 
shouting, or any act which irritates the larynx. The patient's general 
condition is usually good between the paroxysms, unless the latter are so 
severe or attended with so much vomiting as to interfere with the taking 



INFECTIOUS DISEASES. 



181 



of food or with sleeping at night. There is generally fever in proportion 
to the severity of the attack. The nrine is sometimes saccharine, and is 
very frequently albuminous. Any rales which can be detected in the 
chest are due to complicating catarrh. 

The duration of the second stage is generally about four weeks, but 
varies from two to seven or even more weeks. The terminal stage may 
be considered to begin when the symptoms show signs of distinct amelio- 
ration. Its duration is extremely variable ; it may last a single week or 
as much as eight weeks : the average is about a month. The symptoms 
are those of the second stage, with a progressive amelioration, the parox- 
ysms and other attending phenomena becoming not only day by day less 
severe, but also more infrequent. Long after the whoop has disappeared, 
and when the cough is scarcely even paroxysmal, the recurrence of pul- 
monary catarrh from exposure or other cause may bring back typical 
paroxysms. 

Almost invariably there may be found during the acute stage of 
whooping-cough a superficial grayish-yellow ulceration of the fraenuni of 
the tongue, which probably is the result of the mechanical irritation of 
the part by the lower incisor teeth during the violent efforts of coughing. 

Complications. — The most important and fatal complications of 
whooping-cough are inflammations of the respiratory tract. Wide-spread 
broncho-pneumonia is common, and even in the most favorable cases 
runs a very slow and dangerous course. Atelectasis is not infrequent in 
young, weakly, or rachitic children. Emphysema is often developed, but 
very rarely remains after the disease passes by. A paroxysm may end 
in a convulsion ; the convulsion may be purely functional, but it may be 
due to a rupture of a meningeal or other cerebral vessel, and be followed 
by hemiplegia, aphasia, or other evidences of focal organic brain disease. 
In such cases epilepsy, spastic paralysis, aphasia, imbecility, blindness, 
or similar loss of function may be the result of a permanent brain de- 
generation. Eachitic or tubercular tendencies are much intensified by 
whooping-cough. 

Diagnosis. — The nature of those cases of whooping-cough in which 
the disease is so slight as never to go beyond the catarrhal stage can only 
be inferred from the occurrence of the attack during an epidemic of the 
disease. Before the development of the whoop the nocturnal and parox- 
ysmal character of the cough should awaken strong suspicion. A single 
whoop usually settles the diagnosis ; but it must be remembered that a 
severe complicating pulmonary catarrh may prevent the occurrence of 
the whoop, and also that a whooping-cough may insensibly, so tar as the 
symptoms are concerned, pass into a tuberculosis of the lungs. 

Prognosis. — Pertussis is usually regarded as a disease of compara- 
tively little importance, but in feeble children it is a dangerous affection, 
to be treated with great care. According to T. M. Dolan, in London it 
causes one-fourth of the deaths among children. In any individual case 



182 



GENERAL DISEASES. 



the prognosis depends chiefly upon the original condition of the child 
and the care given during the illness. 

Prophylaxis. — Isolation and disinfection are as important and power- 
ful in suppressing the contagion of whooping-cough as of all other dis- 
eases of the class, but, probably because some cases are improved by 
being taken into the air, the disease is continually met with not only in 
public places but in public vehicles. The contagion may not only be 
communicated directly, but may be carried in fomites. 

Treatment. — The hygienic treatment of whooping-cough is of the 
utmost importance. The chief peril to life lies in the probability of 
pulmonary inflammations ; but experience has abundantly demonstrated 
that the confinement of children in even well- ventilated apartments has 
a distinct tendency to aggravate the symptoms, so that very great judgment 
is often required in the obtaining of out- door air without exposure. In 
summer the child should be out in the air the whole day when the 
weather is fine ; in winter out- door exercise should be confined to dry, 
still days on which the temperature is not too low. Winds are even 
more dangerous than damp. In some cases the best results are to be 
obtained by the use of large apartments with very free ventilation. The 
food should be easily digested, palatable, and nutritious. The whole 
tendency of the disease is towards exhaustion. The vomiting may make 
it difficult for the child to obtain sufficient nourishment, so that frequent 
feeding is often judicious. It is essential that at night the child wear 
warm underclothing, at least on the body and arms, in addition to the 
night- wrapper. As in many cases the patient is not frequently seen by 
the physician, the immediate care-taker should note the temperature at 
least twice — better, three times — a day. Any increase of fever should 
be viewed as a danger signal, it being almost always an early indi- 
cation of developing pulmonic catarrh. In advanced whooping-cough 
the greatest benefit is sometimes obtained by change of air, especially 
to sea air. 

The general medicinal treatment is naturally divided into that 
which is directed against the nervous elements of the disease, that which 
has to do with the catarrh, and that which has to do with the general 
support of the system. Mild cases may progress satisfactorily without 
medication, but usually not only the demands of patients for medicine 
but the frequency of the paroxysms and the catarrhal irritation of the 
mucous membrane may be sensibly modified by the administration of 
emulsion of asafetida in very large doses at short intervals. Almost all 
drugs which act upon the nervous system have been given in pertussis ; 
tincture of belladonna is, on the whole, the most generally useful, but 
must be given in sufficient doses to cause slight dryness of the mouth or 
dilatation of the pupil in order to get its full effect. It also acte better 
when given by atomization, so as to have its local benumbing effect upon 
the larynx. Antipyrin and phenacetin are very valuable drugs for 



INFECTIOUS DISEASES. 



183 



checking the frequency and severity of the paroxysms ; they are usually 
well borne, especially phenacetin, and may be given in ascending doses 
until some relief is obtained or some disagreeable symptom is caused. 
Acetanilid is probably as efficacious, but more dangerous. The bromides 
are sometimes of service : the best of them is ammonium bromide ; it may 
be frequently given with great advantage at the same time as antipyrin 
and belladonna, but it is usually much better not to give' the drugs in a 
single prescription, so that the dose of one can be altered without affecting 
that of the others. Bromoform has been very highly recommended, but 
we have had no experience with it, and late clinical reports are not 
favorable : from two to four drops of it may be given to a child three 
years of age three or four times a day. Chloral is a very useful remedy, 
whose administration should be reserved for the late evening, to get its 
hypnotic as well as its anti-convulsive effect ; frequently it may be ad- 
vantageously combined with opium. 

Great benefit is often derived from local treatment. Belladonna has 
already been spoken of, and spraying the larynx with a one per cent, 
solution of cocaine may in some very severe cases be serviceable. If 
there be coryza, the nostrils should be kept clear by washing them out 
with warm salt and water, or with the official peroxide of hydrogen di- 
luted with ten times its bulk of warm, slightly saline water. Saturating 
the air of the room with steam from an atomizer or with water from 
slaking lime often does good. Sometimes benefit is derived from using 
in the steam atomizer a two per cent, solution of carbolic acid or of 
thymol. 

During convalescence the system should be built up as much as pos- 
sible by the use of cod-liver oil, tonics, nutritious food, and change of 
scene. 

MUMPS. EPIDEMIC PAROTITIS. 

Definition. — A contagious, febrile disease, characterized by inflam- 
mation of the parotid gland. 

Etiology. — Although mumps usually occurs in the form of an epi- 
demic, and especially prevails in the spring and autumn, it certainly 
spreads by direct contagion, and probably also by means of fomites. The 
nature of the virus is unknown. Nursing infants are extremely insus- 
ceptible, and adults are not very often attacked, whilst late childhood 
and early adolescence are the ages most susceptible. Males are said to 
be affected more frequently than females. One attack of the disease 
gives immunity, provided both glands have been affected. Cases cer- 
tainly occur in which the mumps attacks only one parotid, and in which 
years afterwards a second attack is confined to the previously unaffected 
gland. It would look, therefore, as though the immunity were a local 
affair. 

Morbid Anatomy. — The changes in the glands consist of hyperemia, 
serous infiltration of the acini, and a catarrhal inflammation of the ducts. 



184 



GENERAL DISEASES. 



Resolution is usually complete, though permanent enlargement of the 
glands may occur. 

Symptomatology. — The period of incubation is from one to three 
weeks. The first symptoms are swelling and pain just below the ear on 
one side, with a slight fever (100° F. ) and some malaise. The swelling 
rapidly increases, passes forward, backward, and downward, and may 
involve the submaxillary gland. In one or two days the opposite side 
usually follows. There is much pain on the attempt to open the mouth, 
so that chewing is greatly interfered with 5 whilst deglutition and even 
speech become difficult. In favorable cases the symptoms subside in 
from seven to ten days, with a rapid convalescence. 

Mumps, though usually a trivial affection, may be a severe one, espe- 
cially in scorbutic, tubercular, or otherwise broken-down subjects. In 
some cases the prodromes are pronounced, and during the attack there 
are high fever, vomiting, rapid pulse, delirium, and great prostration. 
Partial loss of hearing is not rare, and sometimes there is much earache. 
Such symptoms usually subside with the attack, but are liable to leave 
permanent impressions. 

A frequent and curious complication is an involvement of the sexual 
glands. Occasionally in girls the mammse or the ovaries become the 
seat of the irritation and are swollen and painful. In males who have 
already passed through puberty orchitis is very frequent. The left tes- 
ticle is said to be most frequently attacked, but either or both glands 
may be affected. There is marked swelling, with, at times, effusion in 
the tunica vaginalis, and sometimes a subsequent atrophy, which very 
rarely affects more than one testicle. Yulvo-vaginitis or urethritis 
sometimes occurs. 

Diagnosis. — The only difficulty of diagnosis in mumps consists in 
distinguishing between a parotid and a lymphatic swelling. Probably 
the best test is the existence of a point of intense tenderness high up in 
the angle of the jaw immediately behind the auditory meatus. 

Prognosis. — It is doubtful whether death ever occurs from mumps 
in a previously healthy subject unless after exposure and consequent 
secondary complication ; but it is stated that there are epidemics in 
which meningeal symptoms and even death are frequent. 

Treatment. — A laxative, confinement of the patient to bed or to a 
warm room, and a light, liquid diet are usually all that is necessary. 
If there be distinct fever, aconite and antipyrin fever mixture may be 
given. Hot local applications are generally grateful and may be used 
freely, but when there is high inflammatory action cold compresses or 
iced poultices may be preferable, and even leeching may be practised. 
Rubbing the glands with a belladonna- mercurial ointment (equal parts) 
is efficacious when resolution is slow. In typhoid cases appropriate sup- 
port and stimulants should be given. If orchitis occur, absolute rest in 
bed should be enforced, the scrotum well supported, the belladonna-mer- 



INFECTIOUS DISEASES. 



185 



curial ointment used, and, when the tenderness has subsided, strapping 
employed. 

ERYSIPELAS. 

Definition. — A contagious febrile disease, due to the presence of a 
streptococcus which produces at the point of inoculation a peculiar spread- 
ing inflammation, usually accompanied with much serous exudation. 

Etiology. — The contagion of erysipelas consists of the streptococcus 
originally described by Fehleisen under the name of Streptococcus ery- 
sipelatis, but now generally believed to be identical with S. pyogenes. 
As this organism has been found repeatedly in phlegmonous suppura- 
tion, in ulcerative endocarditis, in puerperal endometritis, and even in 
angina with false membrane, it is clear that these diseases are closely 
related to erysipelas. The organism occurs in chains, is non-motile, and 
is not known to form spores. By inoculation of its cultures Fehleisen 
produced typical erysipelas in man. There has been much discussion 
as to the relation of so-called idiopathic erysipelas to surgical erysipelas, 
or erysipelas of wounds. We believe that in medical erysipelas the or- 
ganism finds some crack, excoriation, or abrasion in which it effects a 
lodgement, and that all erysipelas is the result of an inoculation at the 
position of the first outbreak. 

In the development of erysipelas predisposing causes are of great im- 
portance. The disease is rare before puberty, and still less frequent in the 
very old. Certain individuals and even certain families are exceedingly 
susceptible to the poison ; chronic alcoholism, Bright' s disease, excessive 
poverty with its attending hardships, and other influences which lower 
human vitality, are predisposing causes. Eecently delivered women are 
particularly prone to the disease. The contagion is usually not very 
virulent, but it can be conveyed by a third person, and may lurk in 
the furniture or on the walls of an apartment. Under special circum- 
stances not understood the poison of erysipelas becomes endowed with 
great virulence and reproductive power, resulting in epidemics which are 
especially prevalent in the spring months. 

Occasionally erysipelas recurs at comparatively short intervals. In 
such cases it has been rendered extremely probable by the researches of 
Leroy de Lille that the micro-organisms remain in the body in a latent 
state. 

Morbid Anatomy. — Erysipelas is essentially an infectious lymphan- 
gitis, either superficial or deep-seated, and the anatomical alterations are 
both local and general. In superficial erysipelas the local changes are 
essentially of a microscopical character, since the redness and swelling 
observed during life rapidly disappear after death. A furfuraceous des- 
quamation of the epidermis, blisters, pustules, scabs, or sloughs may be 
present. On microscopical examination of hardened, stained specimens 
of the reddened skin, the superficial lymphatics and their radicles, the 
juice-canals, are found to be filled with the erysipelas-coccus. The 



186 



GENERAL DISEASES. 



blood-vessels are distended with blood, and the surrounding tissue is 
infiltrated with leukocytes. 

In deep-seated or phlegmonous erysipelas the subcutaneous tissue is 
infiltrated with a fibrino- serous and cellular exudation in addition to the 
presence of pyogenic cocci. There results a yellowish, gelatinous or 
brawny appearance of the tissue, the color of which may be more or 
less opaque. Necrosis of the inflamed tissue is likely to occur, and the 
skin may be undermined by gangrenous abscesses which tend to break 
through the surface. 

General changes indicative of the infectious nature of the process are 
the swelling of the spleen and the granular degeneration of the heart, 
liver, and kidneys. Chains of bacteria and bacterial emboli may be 
found in the capillaries of various organs. Inflammation of the serous 
membranes, especially of the endocardium, sometimes occurs. 

Symptomatology. — The incubation period is very various, but has 
been assigned as from three to seven days. The local outbreak may or 
may not be preceded by malaise, headache, and vague prodromes, but is 
usually ushered in with an initial chill, which is sometimes very severe, 
and is followed by a rapid rise of temperature. The dermatitis most 
frequently appears near the nasal angle of the eye, or in the immediate 
neighborhood of the nostrils, or in the crease of the cheek which runs 
from the nose to the chin. It inay, however, first develop in the ear or 
in an acne pustule or local lesion anywhere about the head. Shortly 
after or even before the erysipelatous swelling, enlargement of the sub- 
maxillary lymphatic gland can be detected. The color of the inflamed 
skin varies from a rose color to a deep red, is for a moment effaced by 
momentary pressure of the finger, and is accompanied by an elevation of 
temperature of from one to three degrees above that of the healthy sur- 
face. The erysipelatous plaque is slightly elevated, and is often separated 
from the sound tissues by a sharp ridge, which if not visible can be per- 
ceived by the finger. The surface is smooth and shining, and maybe- 
come bullous or vesicular or even pustular within from twenty-four to 
forty- eight hours. In the hemorrhagic form of the disorder which occurs 
in very old or cachectic subjects, the exudate in the vesicles is bloody and 
scattered ecchymoses occur, the whole ending, it may be, in gangrene. 
There is sometimes a burning pain, more commonly an annoying sense 
of tension. As the disease rapidly spreads, the face becomes enormously 
swollen, the eyelids closed, the ears enlarged to twice their normal size, 
and the features obliterated. 

The fever in erysipelas is probably always proportionate to the severity 
of the intoxication, but certainly not to the amount of local lesion. It 
usually reaches 103° to 104° F., with very moderate morning remissions 
(less than a degree), or sometimes with great oscillations, especially in 
severe cases. Often the morning and evening temperatures are a little 
lower than on the preceding day, but there may be steady maintenance 



INFECTIOUS DISEASES. 



187 



or even ascent of temperature until death. In typical cases the local 
lesions cease to advance from the fifth to the tenth day, at which time 
there occurs a rapid fall of the general temperature, amounting, it may 
be, to five degrees in thirty-six or even twenty-four hours. Constitu- 
tional disturbance and adynamia are usually not very pronounced, but 
in the old and debilitated, and especially in alcoholics, the typhoid state, 
with dry glazed tongue, rapid pulse, delirium, and stupor, may develop. 

The subsidence of the local swelling is usually rapid, and may be 
attended by a furfuraceous or sometimes membranous desquamation. 
When the scalp has been invaded the hair often falls out, to return, 
however, in full vigor. Cases have been reported in which white hair 
has been replaced by black, but the contrary is much more common. 
Convalescence is usually rapid, but is sometimes interrupted by cuta- 
neous and other local abscesses. 

Of the varieties of superficial erysipelas made by systematic writers, 
the only one necessary to mention is the so-called E. migrans, in which 
large portions of the body and even of the extremities become inflamed. 

In some cases erysipelas passes into the deep connective tissues of 
the body, producing the so-called phlegmonous erysipelas, which is distin- 
guished from the superficial erysipelas by the greater swelling and darker 
color of the part and by the greater intensity of the pain. The part is 
hard and tense ; after a time it becomes soft and boggy, an evidence that 
suppuration has occurred. Moist gangrene of the skin may follow this, 
with discharge of pus and of shreds or even masses of areolar tissue. 
This form of erysipelas is usually considered a surgical rather than a 
medical disorder, because it especially occurs in connection with wounds 
which enable the poison to get into the deeper fascia of the part. 

Erysipelas of the mucous membranes may arise during an attack of 
external erysipelas or may be primary. When the disease attacks the 
nasal mucous membrane it produces a coryza, with burning pain, head- 
ache, and fever. Erysipelatous stomatitis is rarely primary ; it may be 
accompanied by large pseudo- membranous patches and by pronounced 
stomatitis. Erysipelatous angina differs from catarrhal angina in its 
being excessive, painful, and accompanied by little tumefaction of the 
mucous membrane, but by great swelling of the lymphatic glands and 
high fever. In bad cases phlyctenular appear and may end in gan- 
grene ; retropharyngeal abscesses are not rare. When primitive and 
near the submaxillary glands it is one form of the so-called angina of 
Ludwig (angina Ludovici), and is apt to be accompanied not only by 
severe local symptoms, such as excessive swelling of the submaxillary 
glands and oedema of the glottis, but also by general infection and 
nephritis. If the larynx be involved, serious dyspnoea results. 

As has been especially pointed out by Cornil, erysipelatous pneu- 
monia is distinguished from true pneumonia clinically by the insidious- 
ness of the attack and the rapid spread of the inflammation over wide 



188 



GENERAL DISEASES. 



lung territories ; histologically by the total absence of fibrin from the 
exudate. Erysipelatous gastritis and enteritis may exist as primitive 
diseases, but as such are extremely rare. The genito-urinary mucous 
membrane is very rarely attacked except as the result of distinct local 
infection by the hands of the accoucheur or the gynaecologist. Even in 
puerperal women with facial erysipelas rigorous antiseptic precaution 
will almost invariably prevent the local infection. The vulva should 
be kept well covered with an antiseptic dressing. Erysipelatous or 
streptococcus meningitis, neuritis, pleuritis, arthritis, pericarditis, myo- 
carditis, and endarteritis have been proved to occur, but are less fre- 
quent than endocarditis. Albuminuria is commonly present in ordi- 
nary erysipelas, and of all visceral complications nephritis is the most 
common. 

Diagnosis. — The diagnosis of external erysipelas requires no discus- 
sion. The recognition of the nature of internal erysipelatous inflamma- 
tions without history of exposure to infection is extremely difficult, and 
often impossible. The rapid wide-spread development of the inflamma- 
tion and the serous character of the exudate are the only characteristic 
points. 

Prognosis. — Death is extremely rare in so-called idiopathic erysipe- 
las, unless in very old or feeble subjects. JE. migrans is a very grave 
form, and is apt to be very prolonged. In puerperal or pregnant women 
the prognosis is good so long as inoculation of the genito-urinary tract is 
prevented. 

Treatment. — Erysipelas being a distinctly contagious disease, iso- 
lation and personal disinfection are demanded. The contagion is, how- 
ever, so little active that ordinarily in private houses no great degree of 
caution is essential. In hospitals or where there are wounded or lying-in 
subjects the utmost care should be taken. The obstetrician should refuse 
all cases of the disease when actively employed in his profession. The 
disease being in its beginning a purely local infection, the most natural 
treatment would seem to be local antisepsis. Unfortunately, however, 
cases are rarely seen until such a wide-spread area is affected that local 
treatment avails but little. At one time silver nitrate and iodine were 
much used locally : in our opinion their capabilities are much greater 
for harm than for good. Injections of solution of carbolic acid (two 
per cent.) or of corrosive sublimate (1 to 10,000) just beyond the edge 
of the spreading inflamed area are stated by some practitioners to act 
most happily : we have not used them sufficiently to warrant us in 
giving a personal opinion. Ichthyol is much used ; the skin should be 
thoroughly washed with corrosive sublimate solution (1 to 1000), thickly 
smeared with a mixture of equal parts of ichthyol and vaseline, and 
covered with antiseptic cotton or gauze. The old application of lead 
water and laudanum simply tended to subdue inflammation ; but its 
use in our hands has survived more modern methods. The cold-water 



INFECTIOUS DISEASES. 



189 



dressing dates back to Hippocrates, and perhaps is as good as any other 
local treatment. 

The constitutional treatment should consist of nutritious light diet, 
with stimulants when there is feebleness or adynamia. Tincture of 
ferric chloride should be given in doses of ten to fifteen minims every 
three to four hours, well diluted ; whilst quinine and strychnine may 
be administered in doses proportionate to the weakness. Constipation, 
diarrhoea, restlessness, insomnia, and other untoward symptoms should 
be met as they arise ; but no depressing remedies should be used : large 
doses even of the bromides are too depressing. 

In phlegmonous erysipelas the pus and other products of the disease 
must be evacuated early and thoroughly. For the details of the treat- 
ment the reader is referred to works upon surgery. 

Streptococcus antitoxin serum has been used in the treatment of ery- 
sipelas by Marmorek, Gromakowsky, and a few other observers, with 
alleged good results. Marmorek injected of the serum prepared in the 
Pasteur Institute of Paris ten cubic centimetres, or in very bad cases 
twenty cubic centimetres, followed in twenty-four hours by ten cubic 
centimetres. In one case one hundred and twenty cubic centimetres were 
given in ten days. 

SEPTICEMIA. 

Definition. — A condition due to the absorption into the blood of 
the products of decomposition, or of the organisms which produce such 
changes. 

The definition just given of septicaemia covers two conditions : one 
(saprcemidy septic toxcemia, or septic intoxication) in which no organisms are 
found in the blood ; and one in which micrococci or other septic or- 
ganisms are in the blood (septic infection). 

In many cases of disease the immediate cause of death is a septic 
intoxication superadded to the poisoning of the blood by the products 
of the primary bacterium. Thus, in scarlet fever, in small-pox, in diph- 
theria, in phthisis, and in other acute and chronic disorders, streptococci 
and other organisms flourish in the soil which has been prepared for 
them by the labors of the original pathogenic organism, and greatly aid 
in bringing about a fatal result. It is probable that in all cases of septi- 
caemia there are a primary lodgement and local development of the organ- 
ism which produces the disease ; but certainly there have been cases in 
which the symptoms were indistinguishable from those of a septicaemia, 
yet in which no local deposit of the pathogenic organism was found a< 
the autopsy, though carefully looked for by competent observers. 

That there are two forms of septicaemia, saprsemia and septic infec- 
tion, has been abundantly demonstrated by experiments upon the lower 
animals, and these forms must exist in man, though this has been denied 
by some authorities. A little reflection shows that the term "septi- 
caemia," which arose at a time when the pathology of the disease was 



190 



GENERAL DISEASES. 



not even suspected, is a very general one, covering a large number of 
blood-poisonings, each of which would in a strictly scientifically detailed 
nomenclature have its own name, such as strep toco ccsemia, staphylococ- 
cemia, etc. 

Morbid Anatomy. — Usually at the seat of the local lesion there is 
a decided septic inflammation of the minute lymphatics, accompanied 
by an cedematous condition of the adjacent tissues, swelling of the lym- 
phatic glands, and a host of organisms. The changes throughout the 
body are not very pronounced, consisting mainly of cloudy swelling of 
the fibres of the heart and of the secreting cells of the liver and of the 
kidneys and of the epithelial and other layers of the gastro-intestinal 
mucous membrane, enlargement of the spleen and liver, and an alter- 
ation of the blood, which is remarkably fluid, dark- colored, with little 
tendency to coagulate, and contains often an abundance of organisms. 
Endocarditis is sometimes present. 

Symptomatology. — A pure saprsemia is a rather rare affection, 
except after labor, when the decomposition of retained blood- clots or of 
portions of the placenta or of the membranes may give rise to the rapid 
production of poisons whose absorption is favored by the large exposed 
surface of the uterus and the vagina. Under such circumstances, with 
or without a chill, there may be a sudden rise of temperature, accom- 
panied by free sweating, with nervous disturbance, delirium, and diar- 
rhoea, and, if the symptoms are not checked, a tendency to collapse. 
In ordinary septicaemia the symptoms usually develop rapidly, but not 
with absolute abruptness. The disease may or may not be ushered in 
by a slight chill, but headache, malaise, great depression and anxiety, 
loss of appetite, perhaps nausea, occur, and are accompanied by a fever 
in which the temperature usually ranges from 100° to 102° F. As the 
symptoms increase, a peculiar apathy comes on, and may develop into a 
sort of stupor, out of which the patient can easily be aroused for the 
time being, so as to answer questions intelligently. The gastric disturb- 
ances usually increase, the tongue becomes drier and more coated, the 
febrile temperature rises. Delirium, rapid feeble pulse, great failure of 
strength, hurried irregular respiration, subsultus tendinum, involuntary 
discharges, and death as early as the fourth day, or in protracted cases 
much later, results. 

Symptoms similar to those which have just been described may 
develop without apparent local lesions : to such cases the name cryp- 
togenic septicemia has been given by Leube. Unless, however, in any 
individual case some local focus can be discovered, or unless micro- 
organisms can be found in the blood, the true nature of the attack must 
remain in doubt. Some of these cases are probably the outcomes of 
ptomaine poisonings produced by fermentative changes in the alimentary 
canal, and hence may be looked upon as instances of saprsenda ; in- 
deed, of such nature have been considered the many cases of temporary 



INFECTIOUS DISEASES. 



191 



wretchedness, with or without febrile reaction, which are sometimes 
known as biliousness, and are cured by a free purgation which empties 
the alimentary canal. 

The symptoms of a septicaemia vary somewhat with the nature of the 
invading organism. A streptococcus septicaemia is usually very rapid in 
its course and attended with excessive prostration. A staphylococcus 
septicaemia is commonly slow of development. 

Diagnosis. — The constitutional symptoms of a septicaemia are similar 
to those of most infectious fevers, so that the positive diagnosis of a 
septicaemia must rest upon the discovery of the local infection or of the 
organisms in the blood. When neither of these can be made out, a 
positive diagnosis is not possible. Suspicion should be aroused by the 
presence of the constitutional disturbance without local organic disease 
and without the peculiar symptoms which characterize the infectious 
fevers. 

Prognosis. — The prognosis of septicaemia varies with the nature of 
the invading organism and the situation of its local lesions. A strepto- 
coccus infection is usually much more serious than an infection by a 
staphylococcus. A local colony in the throat is more dangerous than 
one in the finger. Moreover, the same organism varies greatly in its 
virulence : the more rapid the local growth and the development of the 
symptoms, the greater the virulence of the organism and the more serious 
the prognosis. If it be not possible to destroy the primary focus of in- 
fection, the prognosis becomes very serious. 

Treatment. — The only effective treatment of a septicaemia is sur- 
gical, consisting in the thorough opening and disinfection of the wound 
or part in which is the local lodgement of the organism. Careful nursing, 
absolute rest, alcohol in doses proportionate to the depression, moderate 
doses of quinine, the sustaining of the heart and respiration by digitalis, 
strychnine, strophanthus, cocaine, and other stimulants, and the treat- 
ment of various symptoms as they arise, constitute all that can be done 
by the physician. High temperature is to be met by the use of external 
cold rather than by the administration of antipyretics. 

PYEMIA. 

Definition. — A condition produced by the entrance of pyogenic or- 
ganisms into the circulation, clinically characterized by frequent chills 
and an extremely irregular, intermittent fever, with sweating, and ana- 
tomically by multiple metastatic abscesses and various local inflamma- 
tions. 

Probably in all cases of so-called pyaemia there is an absorption not 
only of pyogenic bacteria, but also of septic material produced by decom- 
position of the pus : hence the terms septico-pyamia and pijo-septiccemia, 
used by some authorities. It is evident that septicaemia and pyaemia are 
closely allied and often coexistent conditions. 



192 



GENERAL DISEASES. 



Etiology. — The number of organisms which may under various 
circumstances cause the formation of pus is very large. The so- called 
" essential pus-organisms' 1 are the staphylococcus aureus and staphylo- 
coccus epidermidis albus, the streptococcus pyogenes, the bacillus pyo- 
genes foetidus, and the bacillus pyocyaneus ; but other staphylococci and 
streptococci, as well as the micrococcus lanceolatus, the gonococcus, the 
bacillus coli communis, the bacillus proteus, the bacillus typhi abdomi- 
nalis, the bacillus aerogenes capsulatus, the pneuniococcus, and other low 
forms of life, are capable of inducing suppuration. The organism may 
find access to the general system through the lymphatics from a local 
lesion, which may be undiscoverable (cryptogenic), but probably more 
commonly enters by producing an infectious inflammation of the wall of 
a vein, which leads to a coagulation upon the surface of the inner lining, 
in which the bacteria grow and cause a puriform softening of the throm- 
bus, portions of which become detached and are carried along the course 
of the circulation as infectious emboli. 

Morbid Anatomy. — The anatomical changes characteristic of py- 
aemia as distinguished from septicaemia are those connected with the 
formation of pus in various parts of the body. Hence suppurative 
thrombo-phlebitis, lymphangitis, arthritis, periostitis, osteomyelitis, in- 
flammation of serous membranes, and embolic abscesses are to be found. 
The lesions indicative of septicaemia as differentiated from pyaemia are 
the acute splenic hyperplasia, and the granular degeneration of the heart, 
liver, and kidneys. In septico -pyaemia the focal lesions are associated 
with the degenerative changes in the parenchymatous organs. 

Symptomatology. — An acute pyaemia is usually ushered in by a 
chill, which may be very light or very severe. If an immediate in- 
spection of the wound be made, it will usually be found that the inflam- 
mation has increased, or that a change has taken place in the character 
of the pus. Even during the chill the temperature begins to rise, and 
in the course of from one to a few hours reaches 103° to 105° P., after 
which it drops to normal with a profuse sweat. Usually the next day 
a second paroxysm occurs, and a condition is entered upon in which 
there is a continuous slight pyrexia, attended by great malaise, weakness, 
loss of appetite, nausea and vomiting, emaciation, and recurrent severe 
febrile paroxysms. In these paroxysms the temperature rises from two 
to five or even six degrees with extreme rapidity and falls almost as 
abruptly, the defervescence being accompanied with profuse sweating. 
Symptoms of the typhoid state now come on ; the tongue becomes coated, 
and the pulse rapid and feeble ; but the intellect usually remains clear 
until the last stages of the disease, when delirium and coma appear. As 
the case progresses, erythematous, roseolous, or even pustular rashes may 
develop. 

Local symptoms appear early in a case of acute pyaemia. They are 
the result of the metastatic abscesses, and their nature is, of course, 



INFECTIOUS DISEASES. 



193 



dependent upon the site of the local changes. When the secondary ab- 
scesses are formed in external parts, as the parotid gland or the testicle 
or joints, they can scarcely be overlooked ; but when they occur in in- 
ternal organs the symptoms they produce may be very obscure. Cough 
and expectoration, with dyspnoea, dulness upon percussion, and pleu- 
ritic rub or pneumonic rales, may reveal local changes in the lungs ; 
but pulmonic metastatic abscesses may exist without any distinct dis- 
turbance of the lung function. Empyema is not extremely rare. Jaun- 
dice maybe due to a metastasis into the liver or to a duodenal catarrh, 
but may result from the rapid destruction of the red blood- corpuscles, 
and is, therefore, diagnostic only when associated with hepatic tender- 
ness or increased area of liver dulness. Metastatic infarcts and abscesses 
may develop in the spleen and give rise to enlargement and tenderness, 
though they are somewhat rare. Endocarditis is liable to occur, and 
may be accompanied by distinct physical signs, but in some cases, even 
though there be a great alteration of the valves, muffling and indistinct- 
ness of the heart-sounds are the only changes from the norm. Septic 
conjunctivitis may occur, or panophthalmitis may end in the destruc- 
tion of the eye. Even when there is no pronounced inflammation of 
the organ, white necrotic spots may appear in the retina, with or with- 
out hemorrhage, and are very characteristic. Suppurative periostitis or 
acute osteomyelitis is especially prone to develop when the invading or- 
ganism is the staphylococcus aureus, constituting what was at one time 
known as bone typhoid. Septic nephritis, with infarcts and abscesses, may 
be accompanied by the characteristic urinary changes of acute Bright' s 
disease, but may exist with a normal urine. Wide-spread inflammations 
of the joints are especially apt to occur in the chronic forms of pyaemia 
and septicaemia, giving rise to various so-called rheumatisms. As ex- 
amples may be mentioned the gonorrhoeal and scarlatinal rheumatisms. 

Acute pyaemia runs a rapid course, but the cases grade into the chronic 
form, which may last for months. Chronic pyaemia is characterized by 
irregular fever, with excessive diurnal ranges of temperature (97° to 
103° F.), slight occasional chills, great loss of strength, emaciation not- 
withstanding a good appetite, frequent diarrhoea, progressive anaemia, 
excessive sweating, great feebleness of voice, and death either in an 
exacerbation or from exhaustion. The intellect commonly remains clear 
almost to the last. 

Diagnosis. — The first stage in the diagnosis of a pyaemia is the recog- 
nition of the local disease which produces it. It should be remembered 
that an osteomyelitis, a gonorrhoea, a prostatic abscess, a pyelitis, a tu- 
bercular ulcer in the lungs or elsewhere, in brief, any local disease which 
produces suppuration, may be the source of pyaemia. The disease- 
processes which most closely resemble an acute or a subacute pyaemia 
are typhoid fever, acute miliary tuberculosis, and malarial diseases. The 
irregular intermittent fever which accompanies chronic gall-stones or 

13 



19-1 



GENERAL DISEASES. 



other hepatic disease is in all probability a form of septicaemia : it is to 
be recognized by the persistent local symptoms of gall-stones or hepatic 
diseases. The nature of the malarial disease is to be determined by the 
therapeutic test : an intermittent fever which is not arrested by massive 
doses of quinine is not malarial. 

The diagnostic characteristic points in the constitutional disturbances 
of pyaemia are the irregularities of the paroxysms, the free sweating 
which accompanies them, and the great swing of the temperature. Sep- 
ticaemia may produce similar symptoms ; but in pyaemia the constitutional 
manifestation is soon followed by evidences of multiple local lesions, and 
it is the conjunction of constitutional disturbance with the local lesions 
that makes the diagnosis positive. 

Prognosis. — The distinction between septicaemia and pyaemia is 
largely an artificial one : an abscess may produce a septicaemia with no 
organisms, with few organisms, or with many organisms in the blood ; 
further, the same organism may, under varying conditions, be either sep- 
togenic or pyogenic. Eestriction of the name pyaemia to those cases in 
which metastatic abscesses form has the practical advantage of isolating 
the almost necessarily fatal cases from those which are simply danger- 
ous. We have seen hundreds of cases of acute pyaemia (chiefly during 
our civil war), with but one recovery in a clearly defined case ; septi- 
caemia, on the other hand, is frequently recovered from. Chronic pyaemia 
is usually fatal, but may pass into a condition of partial restoration to 
health. 

Treatment. — The most essential point in the treatment of pyaemia is 
the disinfection of the local source of infection. Unless reinfection can 
be prevented, the case is, of course, hopeless. Alcoholic and other stim- 
ulants should be used ; quinine should be given in sustaining and not 
antiperiodic doses ; strychnine, cocaine, digitalis, strophanthus, and the 
whole list of stimulant drugs and stimulant foods should be used freely 
as demanded by the symptoms. Opium may be employed for the relief 
of pain ; chloral, trional, and sulphonal, if necessary, to produce sleep ; 
external cold for the reduction of high temperature ; and bismuth, as- 
tringents, and opiates for the arrest of diarrhoea ; but no known measures 
have any pronounced influence upon the course of the disease. 

TETANUS. 

Definition. — A febrile disorder, produced by the presence of a 
peculiar bacillus, and characterized by violent tetanic (spinal) spasms, 
continually recurring in response to the slightest peripheral irritation. 

Etiology. — The cause of tetanus is a peculiar bacillus, which was 
first found by Mcolaier in garden- earth, and was afterwards isolated by 
Rosenbach from a wound of a man dead of the disease. It is especially 
characterized by an enlargement of one end, due to the presence of a 
bright spore, which is so resistant to morbific agents that it may be iso- 



INTECTIOUS DISEASES. 



195 



lated by heating materials containing it to 80° Centigrade for one hour, 
at the end of which time all bacilli and all other spores except those of 
tetanus are killed. The tetanus bacillus is also most tenacious of life in 
the presence of ordinary disinfectants, not being killed in ten hours by a 
five per cent, carbolic acid solution, or in three hours by a one to one- 
thousandth solution of mercuric chloride. It develops in almost all media 
at ordinary temperatures, provided there be no oxygen. When inocu- 
lated either from natural or from artificial cultures into men and most 
domestic animals it rapidly grows, but does not enter the lymph or blood, 
remaining, therefore, a local infection. Even for such local growth it 
seems to be necessary for the local bacillus to be accompanied by a poison, 
since when introduced into an animal without the poison which it pro- 
duces it is rapidly destroyed. Certain chemical agents, notably lactic acid, 
are, however, capable of replacing the natural poison. This poison which 
produces the symptoms of tetanus is a toxalbumin of such extraordinary 
virulence that its minimum fatal dose is about one two-hundredth that of 
strychnine, being, it is affirmed, 0.23 milligramme. That it is very rap- 
idly produced after inoculation is shown by the fact that Kitasato found 
that excision of the point of inoculation in the mouse fails to save the 
animal unless practised within an hour after the inoculation. More or 
less time is required for the production of the toxin by the local growth 
of the bacillus, so that the period of incubation of tetanus in man is 
usually between five and ten days, but may be prolonged to three weeks. 
The stage of incubation may, however, be wanting. Thus, Eobinson has 
reported the appearance of tetanus half an hour after the reception of a 
wound of the finger ; whilst, according to Jaccoud, death from tetanus 
has occurred fifteen minutes after the reception of an injury. In such 
cases there has been direct inoculation with an already produced tetanus 
toxalbumin. Mcolaier caused a severe tetanus in himself by pricking 
his hand with a needle moistened with a toxin free from bacilli. 

Tetanus toxin has been prepared from cultures and from the blood and 
urine of tetanized animals. Further, a solid antitoxin has been obtained 
from the blood-serum of horses, goats, and dogs poisoned by the gradual 
introduction of the toxin. 

The peculiarities of the organism, and the fact that it abounds in 
certain soils and localities, explains the facts that punctured wounds, 
first of the feet, next of the hands, are especially apt to cause the disease, 
that men are more frequently attacked than women, and that those who 
work about stables are especially prone to suffer. 

The occasional occurrence of local epidemics of tetanus in man, the 
fact that certain districts are notorious for the frequency of the disease, 
and the belief of veterinarians that certain stables are local centres of 
tetanus, are also in accord with our present knowledge of the nature of 
the poison. It is evident that under unknown favoring conditions there 
is an excessive local development of the organism. 



196 



GENERAL DISEASES. 



In the peculiarities of the tetanic bacillus is to be found the expla- 
nation of certain etiological peculiarities of the disease. Thus, the negro 
race is alleged to be extraordinarily susceptible to tetanus, because in 
some of the West India Islands more than half of all the negro children 
born are known to die of tetanus. The evident explanation of this is to 
be found in the squalor and filth of the negro hovels, which cause them 
to be locally infected with the tetanus organism, so that the ulcers of 
the umbilical cords or the trifling abrasions of the new-born become 
the seats of inoculation. The same explanation attaches to the occur- 
rence of puerperal tetanus among the negro mothers. It is probable 
that heat favors the growth of the bacillus ; certain it is that the disease 
is more frequent in hot climates. Thus, whilst, according to Eosenthal, 
there are in Vienna 2.39 cases of tetanus for one thousand of sick, and 
in Guy's Hospital 1.13 for one thousand, in Bombay the proportion is 
said to be 7.3 for one thousand. Both in India and in New Orleans 
(Louisiana) fatal tetanus has followed upon the hypodermic injection 
of quinine sulphate. 

Much light has been thrown upon the origin of the so-called idio- 
pathic tetanus by Oarbone and Perrero, who very recently found in a 
case the tetanus bacilli in the inflamed bronchi mixed up with pneumonic 
diplococci, and discovered that this form of the tetanus bacillus, so far 
from being strongly anaerobic, flourishes best in the atmospheric air. 

Morbid Anatomy. — Death may occur from tetanus without any 
demonstrable alteration of the spinal cord or in the nerves. In some 
cases, however, there has been an inflammation of the spinal centres ; but 
these and other lesions which have been found by competent observers 
in the bodies of those dead of the disease are not essential phenomena, 
though they may have been the outcome of the excessive irritation of 
the spinal motor centres by the poison. 

Symptomatology. — Tetanus may develop abruptly, but usually the 
characteristic muscular contractions appear after some hours of pro- 
dromes, such as chilliness, stiffness of the neck, and malaise. Occasion- 
ally the spasmodic contractions begin in the part which has been wounded, 
but ordinarily they first appear in the muscles of the jaws, from which 
they pass to the muscles of the neck, the back, and the whole body. 
Violent trismus is, therefore, commonly the first pronounced symptom 
of the disease, and is apt to be accompanied with disorder of the move- 
ments of the tongue and the muscles of the larynx, and, therefore, with 
disorder of the speech. 

As the disease progresses, tetanic contractions of the facial muscles 
produce a peculiar immobility of the face, with wrinkling of the forehead, 
drawing up of the corners of the mouth, exposure of the firmly closed 
teeth, and wide-open staring eyes, — the " sardonic grin." The great 
deepening and stretching of the lines of the face produce, also, an ex- 
traordinary appearance of age. Owing to the greater strength of the 



INFECTIOUS DISEASES. 



197 



muscles of the back, the head is usually drawn somewhat backward, 
whilst the spinal column is so bent that the chest and upper abdomen 
are thrust forward and the body rests upon the head and shoulders and 
the buttocks (opisthotonos). The abdominal muscles are rigidly con- 
tracted, 'flattening out the belly j whilst the lower limbs are immovable 
in extension. The arms usually can still be controlled by the patient. 
In rare cases, by the irregular muscular contractions the body is thrown 
into emprosthotonos or even into pleurosthotonos. Painful erections of 
the penis sometimes occur, but are rare. 

In some cases the tetanic rigidity is continually maintained. Severe 
clonic contractions often occur, involving the whole muscular system, 
and producing violent shocks, intense opisthotonos, and thrusting forth 
of the tongue, which may be badly bitten. The respiration may be so 
interfered with that there is a pronounced sense of suffocation, and a 
cyanosis, which may go on until unconsciousness and even death result. 
In very mild cases these crises may not be pronounced ; in the more 
severe cases they are liable to be produced by the slightest peripheral 
irritation, such as may be caused by a jar of the bed, a draught of air, 
or even a loud sound or a bright light. They are often worse at night 
than in the day 5 hence there is usually pronounced insomnia ; but when 
sleep is obtained the spasm ceases, to recur upon awaking. The muscular 
contractions, especially in the clonic movements, are accompanied by 
muscular pains, which may be very violent, and sometimes also by a 
hyperesthesia, though the tactile and thermic senses have been noted in 
individual cases to be distinctly diminished. The intelligence is not 
affected. Local or even wide- spread paralyses have been recorded, but 
are uncommon. 

In the onset of the disease the temperature is usually normal or 
slightly elevated, but later the fever becomes very pronounced, and in 
fatal cases, just before death, the temperature often rapidly rises, reach- 
ing, it may be, 110° and continuing to go up for some time after 
death. The pulse often remains normal for a long time, but sooner or 
later becomes very rapid (even 180 per minute), small, and somewhat 
irregular. The urine in occasional cases contains albumin or sngar. 
Various systematic writers state that there is no increase of the excretion 
of urea ; but our present evidence is too contradictory to warrant any 
positive conclusion. Senator, who failed to find increase of the urea, 
found lessening of the creatin and creatinin. Hupert discovered a dis- 
tinct increase in urea elimination. 

There is no definite course to tetanus : it may end in a few days, 
usually fatally, or may drag on for weeks. When recovery takes place, 
it is usually by a gradual subsidence of the symptoms. In relation to its 
course, tetanus may for the purpose of its discussion be divided into the 
foudroyant form, in which death occurs in a few hours, it may be even 
before the muscular contractions become general ; the acute or ordinary 



198 



GENERAL DISEASES. 



form 5 and the chronic variety, in which the symptoms are mild and 
stretch over many days. 

Under the name of cerebral tetanus has been described a condition 
which originates from a wound of the head and is characterized by 
paralysis of the facial muscles on the same side as the wound, with tris- 
mus and difficulty of swallowing. How far this is the same disease as 
ordinary tetanus remains somewhat doubtful. 

Tetanus neonatorum, or tetanus of the new-born, usually appears about 
the fifth or sixth day after birth, with prodromic restlessness, failure 
of appetite, and general illness, followed by trismus, facial contraction, 
difficulty in deglutition, and tonic muscular contractions, which spread 
through the whole body as in ordinary tetanus, and terminate after two 
or three days either in fatal asphyxia or in collapse. 

In the so-called idiopathic tetanus, which originates without a wound, 
the symptoms are usually not nearly so severe as in the traumatic affec- 
tion, and the course is almost invariably prolonged. 

Prognosis. — There is an extraordinary difference in the statements 
of authorities concerning the mortality-rate of adult tetanus. Thus, 
Eeichter in battle-field cases gives the mortality-rate as eighty per cent. ; 
in civil cases the mortality is, according to Marcosignori, twenty-five per 
cent. ; to Albertoni, twenty-one per cent. ; to Gowers, ninety per cent. ; 
to Dean, eighty per cent. ; to Sormannie, forty-four per cent. ; to Osier, 
eighty per cent. In infants the prognosis is practically fatal ; in older 
children the disease is less dangerous than in adults ; in puerperal tetanus 
recovery is almost unknown. In attempting to decide the chances of 
individual cases, it should be remembered that the shorter the time that 
has elapsed between the injury and the coming on of the symptoms the 
worse the prognosis. Thus, J. T. Whittaker gives the mortality as 
ninety-six and six-tenths per cent, when the interval has been less than 
ten days, and eighty-four per cent, for all cases. Further, the result is 
almost invariably proportionate to the early severity of the symptoms, 
and the greater part of the deaths take place in the first week : so that 
if this period be survived the chances of recovery are at least fifty per 
cent. After survival for two weeks the danger is comparatively slight. 
From the best obtainable statistics it would appear that in cerebral 
tetanus the mortality-rate is in acute cases over ninety per cent. ; in 
chronic cases about twenty-five per cent. In idiopathic tetanus more 
than fifty per cent, recover. The favorable indications are late onset, 
general lack of intensity of the convulsions and their confinement to the 
muscles of the jaw and neck, absence of fever, and a tendency to a 
general slow course. When the disease develops early and the symp- 
toms are from the beginning severe, there is almost no hope. 

Diagnosis. — The characteristic symptoms of tetanus are the early 
occurrence of trismus, the steadiness and universality of the tetanic con- 
tractions, the presence of fever, and the length of the course. It may 



INFECTIOUS DISEASES. 



199 



be closely simulated by hysteria, in which case, however, there will be 
almost invariably a history of previous existence of hysterical tempera- 
ment and emotional disturbance, and a more or less partial character of 
the convulsions. In strychnine poisoning the course is more acute than 
is ordinarily seen in tetanus. Trismus, if it occur at all, comes on as a 
late symptom, and the relaxation between the convulsive crises is more 
pronounced than in the ordinary disease. In certain stages of strychnine 
poisoning the diagnosis without history may be almost impossible. The 
toxin of tetanus is eliminated by the kidney, so that if in a doubtful 
case injection of the urine should produce immediate tetanic convulsions 
in a rabbit the diagnosis would be clear. A negative result, however, 
does not disprove the existence of tetanus. 

Treatment. — In order to prevent the development of tetanus, punc- 
tured wounds, especially in the extremities, should always be freely 
opened and thoroughly disinfected ; and even after the occurrence of 
tetanoid symptoms free excision of the wound or of its scar and cauter- 
ization should be practised, so as to break up, if possible, the local bacil- 
lus colony and prevent a further formation of the toxin. It is essential 
that the patient be put on a wide bed in a darkened, very quiet room, and 
kept absolutely free from all disturbances. A slight draught may pro- 
duce a fatal convulsion. Bromide of potassium should be given in very 
large doses in diluted solution. Half an ounce of it should be exhibited 
at a dose as soon as the case is seen. If the symptoms be severe, drachm 
doses should be administered at intervals of from three to six hours. 

Almost any of the spinal depressants may be useful in tetanus. 
Chloral is of special value because of its tendency to produce sleep. It 
may in very acute cases be used continually day and night, but in chronic 
cases it is better to employ it at night in order to obtain sleep. Under 
these circumstances it is best administered in combination with opium. 
Twenty to thirty grains of chloral, with one-fourth of a grain of morphine, 
may be given at a time, and repeated, if necessary, in half a dose. The 
combination of chloral with hyoscine hydrobromate is sometimes very 
serviceable. Calabar bean extract has been much used, with not very 
gratifying results. On account of its varying strength, it should at first 
be given in small doses, one-sixth of a grain, which may be increased. 
Eserine in the dose of one-fiftieth of a grain, at intervals of from four 
to six hours, increased if necessary, is preferable to the extract. Opium, 
given continuously in small doses up to mild narcotism, is often very ser- 
viceable. Chloroform and the nitrites are of the greatest service, but 
are fugitive in their action, and therefore should be especially used in 
the crises of convulsions. Nitroglycerin (Spiritus glonoini, U.S.), being 
more persistent in its influence, is for a steady effect preferable to the 
other nitrites, but even it should be given at intervals of not less than 
an hour (dose, one to two drops). Cannabis indica is largely used in 
India and much relied upon, given to the point of intoxication. 



200 



GENEBJlL diseases. 



In administering these various remedies it must be remembered that 
none of them are specific, and that the sufferer from tetanus may go on 
rapidly to death although the convulsions are for the time being set aside. 
It is plain, therefore, that, whilst very large doses are necessary, it is 
often better to subdue the convulsion than to overcome it completely ; for 
such complete overcoming may demand the use of doses so large as to be 
distinctly depressant to the heart or the general system. Further, in 
chronic cases it is essential to vary from day to day the spinal de- 
pressant, so as to prevent the system from becoming accustomed to any 
one remedy, and to put aside the danger of any accumulation of the 
drug. In many cases digitalis may be added to prevent heart- weakness. 

As there is a toxic adynamia, alcohol is indicated. Moreover, alco- 
hol in large doses is a spinal depressant, so that for a double purpose 
it should be freely employed. Owing to the impossibility of chewing, 
and the common difficulty of swallowing, concentrated liquid food should 
be administered in as large quantities as the patient can digest. If the 
trismus be very severe, the patient should be fed by a tube through the 
nose, or sometimes a tooth may be extracted so as to allow the passage 
of a tube into the mouth. If there be obstinate constipation, mild laxa- 
tives should be given. Injections are liable to produce reflex convulsions. 

In the laboratory artificial tetanus x)roduced in various animals can 
be certainly controlled by early treatment with antitoxin, but in practi- 
cal human medicine the affair is entirely different, because there can be 
no estimate of the amount of toxin in the body, and especially because 
treatment cannot be commenced until the toxin has permeated the whole 
system. 

Howlett found in sixty -eight cases of all forms of tetanus treated with 
antitoxin a mortality of thirty-six per cent. ; in an elaborate analysis 
of fifty-four cases Kanthack has shown that in the more acute cases, 
with an incubation period of less than eight days, the mortality has 
been eighty-five and seven-tenths per cent., but in the chronic cases 
only five and seven-tenths per cent. Kanthack gives strong reasons for 
believing that many fatal cases have not been reported, and seems to 
us to be fully justified in his conclusion that in acute tetanus the anti- 
toxin is practically powerless. On the other hand, it appears probable 
that in chronic cases the remedy has distinct value. In regard to the 
amount used, Kanthack shows that as the manufacture of antitoxin has 
improved, the dose has decreased steadily from over fifteen grammes to 
nine-tenths of a gramme. 

The first dose of the antitoxin serum of Behring and Eoux is put 
down as from twenty to thirty cubic centimetres ; the after-doses, given 
at intervals of from five to ten hours, are from fifteen to twenty cubic 
centimetres. Antitoxin prepared by Tizzoni and Cattani, near Bologna, 
is furnished in a dry state in small flasks, which must be kept sealed 
until the time of use, when their contents are dissolved in distilled water 



INFECTIOUS DISEASES. 



201 



recently boiled and allowed to cool, one part by weight in ten parts by 
weight of water. The injection is to be practised in the thigh with a 
syringe which has been rendered aseptic by heat, not by chemical dis- 
infectants. In a mild case in the adnlt half of the contents of the vial 
is to be injected as the initial dose, and the remainder is to be divided 
into four doses, to be used at intervals the following day, according to 
the necessities of the case. If the case be seen late, or if the incuba- 
tion period has been very short, or the symptoms are severe, the first 
injection should contain the whole contents of the vial, and a second 
vial be used the next day. With children the doses are to be about one- 
half. In very severe cases larger doses than those above mentioned may 
be given. The use of the antitoxin should not interfere in any way 
with the other treatment of the disease. 

Overshadowing the use of antitoxin is the practical difficulty of pro- 
curing a pure article. We have seen increase of fever and other symp- 
toms produced by the use of a standard antitoxin, and other similar 
cases have been reported. It is probable that the antitoxins used in 
these cases contained toxin. As one ten-thousandth of a grain of toxin 
might seriously injure a patient, the danger of trusting to any manu- 
facture of tetanus antitoxin is obvious. 

MALARIAL DISEASES. 

Definition. — Affections which are produced by the presence in the 
human body of a peculiar ha^matozoon. 

Etiology. — Malarial diseases are not contagious, and do not pass 
from man to man ; they are the outcome of a poison which is produced 
outside of the body. For the production of this poison there are required 
a proper soil, an abundant moisture, and a sufficient heat. As these con- 
ditions are wide-spread, malarial districts are found from the subpolar 
regions to the equator. As a rule, the extent of the infected districts 
and the virulence of the poison which emanates from them steadily in- 
crease with the heat of the climate, so that the most deadly malarial 
countries are tropical or subtropical. The character of the soil neces- 
sary for the production of malaria is not thoroughly understood ; it is 
certain that an alluvial soil is an especially fit habitation, and it would 
seem that the suitability of the soil usually increases with the amount 
of vegetable organic matter in it. There are, however, especially in 
the colder malarial countries, great differences in neighboring localities, 
which cannot be accounted for with our present knowledge. It is prob- 
able that there are organic or inorganic constituents of certain soils 
which inhibit the growth of the malarial organisms and therefore render 
healthful a certain swamp in an infected district. The amount of moist- 
ure in a soil has immense influence : if a tract be covered all the time 
with even a very shallow depth of water, it is almost innocuous ; if it be 
alternately exposed and covered with the changes of the tide, it may 



202 



GENERAL DISEASES. 



be very dangerous ; but the most deadly of all localities are those in 
which, without there being water upon the surface, the ground-water 
reaches close to the top of an alluvial soil containing much organic matter. 
It was such a soil that in the famous Walcheren campaign in 1809 put 
twenty-seven thousand out of forty thousand English soldiers into the 
hospital. As a rule, the deltas of rivers and the country around great 
fresh-water lakes are abundant producers of malaria. Thus, in Europe 
the valleys of the Po, the Tiber, the Danube, and the rivers of the Black 
Sea are the chief sources ; whilst in America the valleys of the Dela- 
ware, the Chesapeake, and the rivers in general of the southern United 
States, with certain portions of the shores of the great lakes, are the 
most dangerous localities. The damming of rivers and the drainage 
of marshes are powerful factors for increasing or decreasing the produc- 
tion of malaria. Cultivation of the soil in some way seems to lessen its 
productive power, so far as malaria is concerned. As an instance of the 
changes wrought by artificial means may be mentioned the Schuylkill 
Eiver, which in the beginning of the present century was so slightly 
malarious that on its banks were the habitations of the wealth of Phila- 
delphia ; the river was dammed, and the banks became uninhabitable ; 
then paddle-wheel steamers were put upon the dam, and, either as a 
result or as a coincidence, there was almost complete disappearance of 
the malaria. 

Changes take place, however, in the production of malaria which 
are not easily accounted for. It is clear that there has been a great de- 
crease of malaria in New England and in the Middle United States, 
whereas it is asserted that about the ports of the Gulf States the disease 
is, on the whole, increasing. Can this be by the importation of fresh, 
extremely virile germs from the tropical islands and mainland? It is 
affirmed that malaria has disappeared from Lake Ontario ; and in the 
Northwestern States it is almost unknown. How far it is capable of ex- 
tending northward is somewhat uncertain, but the St. Lawrence region 
in America and the wide marshes of St. Petersburg are unpolluted. 

Age has little or no influence upon the susceptibility to the malarial 
poison, and instead of an attack affording protection against the disease 
it renders the subject much more liable. Nor is there, so far as observa- 
tion goes, any hereditary insusceptibility ; the white races, at least, do not 
become accustomed to the disease, but, in fact, degenerate in the face of a 
persistent overwhelming malarial poison. On the other hand, the negro 
races, and, it is affirmed, to a less degree also the Arabs, enjoy almost an 
immunity. As a certain degree and persistence of heat are necessary for 
the development of the malarial germ, the late summer and the early fall 
are the seasons of greatest danger. In certain seasons the relations of 
temperature and moisture are such as greatly to stimulate the growth of 
the malarial germ ; but, independently of such open climatic influences, 
there are in some years violent malarial epidemics. 



INFECTIOUS DISEASES. 



203 



It is plain that ordinarily in thickly populated cities the conditions 
are not favorable for the development of the germ, hence malaria is a 
disease of the country rather than of the town ; but it is not true that 
complete protection is afforded even in the most thickly populated city. 
Heavy fogs and the moist air of night favor the rising from the ground 
and the dispersion of the malarial poison. Moreover, owing probably to 
mechanical reasons, high elevation above the earth affords protection, and 
the obstruction of a high wall or a dense wood may be sufficient to alter 
distinctly the malarial relations of a certain place. High winds may 
carry the germs to a considerable distance. 

In 1879 M. Laveran, a French army surgeon, announced the discovery 
of a hsematozoon, the germ of malaria. This discovery was confirmed in 
1882 by Eichard, in 1884 by Marchiafava and Celli, and since by numer- 
ous observers in Europe, Asia, and America. The malarial organism 
is usually believed to belong among the sporozoa. Its life-history out- 
side of the body is unknown. So far, all attempts to grow the parasite 
have entirely failed. Nor as yet have we knowledge as to how the germ 
enters the blood. The experiments of Gerhardt, of Marchiafava and 
Celli, of Geraldi, and of others, have shown that intravenous or even 
hypodermic injection of blood may transfer the disease from man to man ; 
but all attempts to pass the hseniatozoa through the alimentary canal into 
the system have so far failed. Inside of the body the hsematozoa have 
a regular cycle of existence within the red blood-corpuscles ; at first they 
consist of small hyaline amoeboid bodies which develop within the red 
blood- corpuscles ; these bodies as they grow in size become replete with 
minute dark pigment-granules that have been formed out of the hsenio- 
globin. After a time, when the red blood- corpuscles have been destroyed, 
the parasites divide into a number of small round or ovoid transparent 
bodies, each of which breaking away attacks a new corpuscle and enters 
a new cycle of life. As was first pointed out by Golgi, the parasites of a 
regularly intermittent fever exist in the blood in great groups composed 
of individual elements at about the same stage of development : in conse- 
quence of this, many thousands of parasites undergo sporulation at or 
near the same time, which sporulation is always followed by the malarial 
paroxysm : so that it would appear as if the febrile reaction were caused 
by some poison produced in the process of development of the parasite. 
Whether the malarial fever shall take the tertian, the quartan, or the 
quotidian form probably depends upon the rate of development of the 
hsematozoa, although there seems to be still some doubt whether there 
are hsematozoa which pass through the whole cycle in twenty- four hours 
and produce the quotidian paroxysms. There appear also to be differ- 
ences in the organisms corresponding with clinical differences in the 
malarial disease. 

The parasite of tertian fever grows from a minute hyaline body into a 
full-grown organism about the size of a red blood-corpuscle, whicli do- 



204 



GENERAL DISEASES. 



velops by segmentation into fifteen or twenty spornles in about forty -eight 
hours ; the smaller parasite of the quartan fever requires seventy-two 
hours for its life- cycle, and produces usually from five to ten spornles, 
which are commonly arranged about a central mass of pigment so as 
to form a rosette. There may be in the blood two or more groups of 
organisms ; if there be two groups of tertian or three groups of quartan 
organisms, each group passing through its own successive cycles inde- 
pendently, a series of quotidian paroxysms will result. 

The parasite of remittent malarial fever varies from the other mal- 
arial organisms in being considerably smaller, and in giving rise to 
large, refractive, crescent ic, ovoid, and round bodies, with central clumps 
of coarse pigment-granules, whose significance has not been determined. 
From these bodies, as well as from the tertian and quartan parasites, 
long, active fiagella may develop, so that the hseinatozoa move freely 
among the blood-corpuscles. 

It is evident that the anaemia and the pigmentation of paludism are 
the direct results of the destruction of the red blood-corpuscles by the 
parasites. Further, severe cerebral symptoms may be produced by the 
filling up of brain capillaries by the organism, which have also been 
detected in great quantities in the capillaries of the gastro-intestinal 
mucous membrane in malarial cases that have suffered from choleriform 
diarrhoea. 

In bad cases of malarial fever there is probably produced at each 
sporulation almost a sufficiency of parasites to destroy all the red blood- 
corpuscles of the body. Moreover, it is well known that cases of malarial 
fever may get well spontaneously. It is, therefore, evident that there 
must be some provision for the destruction of the parasites in the blood. 
There are at present two theories : in accordance with one, the blood- 
serum kills the simple hyaline forms before they gain entrance into the 
red corpuscles ; in accordance with the other, certain cells act as phago- 
cytes. Although authorities are not agreed, the present evidence indi- 
cates that each of these theories is in part correct, — that is, that the 
parasites are killed by the blood-serum and also by phagocytes. 

There appear to be at least three sets of phagocytes : first, leukocytes 
of the blood ; second, the endothelial cells of the arterioles throughout 
the body ; third, certain of the parenchymatous cells, especially the cells 
of Kupffer in the liver and the pulp-cells of the spleen. A phagocytic 
cell may contain any or all of the following : 1, red blood- corpuscles, 
normal, altered, or in fragments ; 2, masses of hsemosiderin (probably 
formed within the cells) ; 3, malarial parasites in different phases of the 
developmental cycle, many of them degenerated or going to pieces ; 4, 
malarial pigment, especially the central pigment clumps from segment- 
ing parasites ; and 5, white cells, both mononuclear and polynuclear. 
Again, certain large cells contain other phagocytes with their contents. 
According to L. F. Barker, leukocytes are especially apt to contain well- 



INFECTIOUS DISEASES. 



205 



preserved parasites, whilst the large phagocytic cells of the spleen — 
makrophages — and liver contain with the parasites large numbers of in- 
fected red blood-corpuscles. Golgi has brought forward evidence that 
there is a periodicity of the phagocytosis corresponding to the develop- 
mental cycle of the parasite. 

The observation of Dock, that the malarial parasites are arrested in 
their development soon after the death of a patient, strongly indicates 
that phagocytosis is not the only method of their destruction in the body. 

Morbid Anatomy.— -The anatomical changes occurring in the milder 
forms of malaria are but little known, since patients rarely die. The 
fatal cases are usually those of pernicious malaria, in which the conspicuous 
changes are to be found in the spleen. This organ is enlarged to a greater 
or less extent, is dark-colored, and of diminished consistency. On section 
the pulp resembles dregs of paint. The follicles and trabecular are in- 
distinct. At times nodules of hemorrhagic infarction are to be found, 
and rarely rupture of the capsule may occur. The liver and kidneys are 
swollen and opaque. Pigment-granules from degenerated blood-corpuscles 
may be found free or enclosed within leukocytes, in the spleen, and in the 
blood-vessels of the liver, kidneys, intestine, and brain. Foci of necrosis 
have been found in the liver and kidneys. In patients dying from ex- 
posure to chronic malaria the enlarged spleen is dense, its capsule and 
trabecular thickened, and on section the color is either brown or black. 
The liver is enlarged and increased in density. On section the color is 
composed of shades of gray or bluish-gray, with a tendency to the forma- 
tion of dark patches. The pigment is especially abundant in the vicinity 
of the blood-vessels, and the connective tissue is somewhat increased. 
A similar grayish slate-color from the presence of particles of black 
pigment may be present in the kidneys, brain, and bone-marrow, and 
sometimes in the mucous membrane of the stomach and intestines. 

Symptomatology. — The paroxysms of an intermittent fever may 
commence suddenly, or may be preceded by malaise, anorexia, or other 
general prodromes. The typical attack is composed of three stages, — the 
chill, the fever, and the sweat. The first stage commences with a feeling 
of cold in the back, which soon radiates into all portions of the body, 
and is accompanied with horripilations, which may become so violent 
that the teeth chatter, whilst the body trembles sufficiently to shake 
the couch upon which the patient lies. The skin is pale, cold, and by 
contraction of the erector pili muscles thrown into goose-flesh. Ver- 
tigo, cephalalgia, ringing in the ears, troubles of vision, dilated pupils, 
vomiting, abundant urination, and frequent, small pulse are common 
phenomena. Notwithstanding the coldness of the surface and of the 
extremities, the bodily temperature begins to rise at the very onset of 
the attack, so that before the chill is over 104° or 105° F. may be reached, 
and the surface be extremely hot. Gradually the cold stage passes into 
that of fever, with brilliant eyes, congested face, strong, perhaps dicrotic, 



206 



GENERAL DISEASES. 



pulse, furious headache, and various nervous disturbances, such as mental 
confusion, unrest, and even delirium. Usually in from three to four 
hours, hut in some cases not until ten or even more hours, the hitherto dry 
skin breaks out into a profuse perspiration, which is followed by a rapid 
fall of the temperature to 98.5° F., and commonly in from two to four 
more hours the subject has apparently recovered his normal condition. 
In some cases there can be detected during the stage of fever an enlarge- 
ment and tenderness of the spleen, which abates during the sweating 
stage. Maissuriany affirms that an intermittent splenic bruit synchro- 
nous with the pulse may sometimes be heard. The urine examined at 
the end of the paroxysm is often albuminous, and, according to Eich- 
horst and others, there is an increase of the urea and of the phosphoric 
acid, and a decrease of the chlorides, during the whole paroxysm. The 
observation of Brousse, that the urinary toxicity is increased by the 
paroxysm, was not confirmed in the experiments of Laveran. 

The return of the paroxysm of intermittent fever depends upon the 
type to which the attack conforms. In the quotidian the paroxysm recurs 
daily ; in the tertian, every other day ; in the quartan, every third day. 
Typically, the hour of recurrence should be that of the first attack, but 
very commonly in an intermittent fever each paroxysm appears two or 
even more hours before it is due. On the other hand, especially under 
the influence of not sufficiently large doses of quinine, the intermittent 
fever often undergoes retardation, so that the paroxysms are one or more 
hours behind time in their appearance. The malarial paroxysm occurs 
almost always in the daytime, and when the paroxysm of an accelerating 
or retarding intermittent comes to the night it is very prone at one leap 
to jump over the whole period of darkness. The cause of the rarity of 
nocturnal attacks of intermittent fever is not certain. We have seen, 
however, in a watchman who habitually slept during the day and worked 
at night, nocturnal instead of diurnal paroxysms. 

Varieties in the intermittent paroxysms are very common. In the 
majority of cases as seen in the latitude of Philadelphia the chill is very 
slight or altogether wanting. The sweating stage is also frequently not 
pronounced, so that the whole paroxysm is reduced to from six to ten 
or perhaps more hours of a mild fever with headache. 

The variations in the intermittent paroxysm may be so great that 
the typical febrile attack is entirely replaced by a new set of phenomena. 
Thus, violent urticaria attended with almost delirious excitement may 
replace the chill, and is said also sometimes to constitute the whole par- 
oxysm. The most common of these irregular intermittents is that which 
is known as brow ague, in which the attack consists of a violent pain 
centred in the supraorbital foramen, filling the whole side of the head 
with agony, attended in rather exceptional cases with great depression, 
and perhaps with vomiting. In some cases the malarial attack may con- 
sist of frightful neuralgic pain in the trunk or the extremities. In a 



INFECTIOUS DISEASES. 



207 



somewhat rarer form of irregular malarial fever, of which, however, we 
have seen a number of cases, the attacks consist of a recurring serous 
or choleriform diarrhoea, which yields to no treatment except that which 
is antimalarial. A very rare variety which we have seen once or twice 
is that in which the whole paroxysm consists of a protracted epilepti- 
form convulsion, which may so closely resemble the convulsion of idio- 
pathic epilepsy as to lead to the diagnosis of that disease. It is asserted 
that the irregular malarial paroxysm may take the form of recurring 
attacks of congestion of the lungs, each attended with the physical signs 
of an incipient pneumonia. Paroxysmal paraplegia and other paralyses 
have been reported from time to time as of malarial origin. 

Remittent Fever. iEstivo- Autumnal Fever. — The bilious remittent 
fever, or simply the bilious fever, of the Southern United States differs 
clinically from ordinary intermittent fever in having the paroxysms so 
prolonged that they run into one another without any complete inter- 
mission. The types of the paroxysms are the same as in ordinary inter- 
mittent fever, quotidian, tertian, and quartan, though the quartan type 
is extremely rare. Next to the quotidian in frequency is probably the 
double tertian, in which there are two daily paroxysms at different times 
of day : the first paroxysm occurs in the morning, the second in the 
evening, of the first day ; the third paroxysm in the morning, the fourth 
in the evening, of the second day ; and so on. Eemittent fever usually 
comes on with distinct prodromes, such as malaise and epigastric weight 
and fulness. Often there is a chill, mostly mild in character, followed 
by a violent febrile reaction, with heavily coated tongue, extreme thirst, 
nausea, and vomiting. At this time the pulse is usually infrequent in 
proportion to the fever. In from eight to twenty hours a remission 
occurs, with mild perspiration and lessening of the symptoms, to be 
succeeded by a paroxysm of fever like the first. In this way arises a 
fierce fever with regular remissions and paroxysms. The pulse becomes 
more rapid, rising, it may be, to 120 a minute, and the skin dries. 
Epigastric pains and tenderness, with nausea and vomiting, are common 
symptoms, and are usually associated with constipation, green, black, or 
yellowish, very offensive stools, scanty urine, and the appearance of a 
yellowish hue of the skin and conjunctiva, which by the fifth day of 
the disease has usually deepened into the bronze of a pronounced jaun- 
dice. At this time very commonly hepatic enlargement and tenderness 
can be demonstrated. The nervous symptoms may consist simply of 
headache, with apathy and a mild somnolence, but stupor and delirium 
are common phenomena. In favorable cases the symptoms gradually 
abate, the first evidence of change often being frequent copious dark tar- 
like discharges from the bowels. In very unfavorable cases the symptoms 
of vital failure come on early, and with a dusky, livid, purplish, or 
bronze skin, cold extremities, dark-brown tongue, tympanitic abdomen, 
and low delirium ending in stupor or coma, the patient passes on to 



208 



GENERAL DISEASES. 



death, which usually occurs between the seventh and the fourteenth 
day of the disease. Under these circumstances there are often excessive 
vomiting, not rarely hiccough, and sometimes black or bloody, persistent 
diarrhoea. In another set of cases the symptoms are said to assume more 
and more the appearance of a typhoid fever, with the remissions little 
marked and the stupor, subsultus tendinum, carphologia, and other symp- 
toms of adynamia strongly pronounced. 

Pernicious Fever. — Malignant or congestive malarial fever may sud- 
denly develop out of an ordinary miasmatic fever, or may come on ab- 
ruptly during apparent good health. Three forms of it, the algid, the 
comatose, and the hemorrhagic, are described by systematic writers. 
The divisions are, however, arbitrary. 

In the algid malarial fever, as ordinarily seen, there are livid paleness 
of the face, with an expression of alarm, and often of collapse, great cold- 
ness of the extremities and sometimes even of the surface of the body, 
and an abundance of colliquative sweat. The internal temperature may 
be below or above normal. There may be oppression, epigastric weight, 
intense thirst, violent vomiting, and choleriform diarrhoea. The respira- 
tion is apt to be hurried, irregular, panting, not rarely sighing, with 
occasionally each inspiration interrupted in its progress and effected as 
by a double effort. The small, irregular pulse may be corded or may be 
feeble ; not rarely it is intermittent, sometimes as high as 170 a minute. 
Great restlessness and uneasiness, with a complete retention of conscious- 
ness, may exist, as in " walking cholera," clearness of mind and the ability 
to go about the room remaining when the pulse is imperceptible. These 
symptoms may increase until death takes place quietly in collapse, or may 
be followed by reaction and fever. 

In the comatose variety there is marked cerebral disturbance, with 
partial or complete unconsciousness and symptoms of collapse, or with 
high fever ending in death with profound coma. 

In cases of algid pernicious fever the dejections may consist of bloody 
serum or of pure blood, but the typical hemorrhagic form is that in which 
either hematuria or hemoglobinuria is the most prominent symptom. 
In some of these cases the general symptoms resemble those of bilious 
fever, with chill, violent vomiting, intense lumbar rachialgia, high fever, 
and jaundice. In other cases the febrile paroxysm is wanting, the only 
symptoms being haemogiobinuria, lasting from twelve to thirty-six hours, 
violent perspiration, and collapse. The urine is albuminous ; it contains 
an abundance of haemoglobin, and often, although not always, entire blood- 
corpuscles. 

As seen in the neighborhood of Philadelphia, pernicious fever offers 
a mixture of the symptoms of the algid and comatose forms. The 
haematuric form occurs in the extreme southern United States, and also 
in the tropical portions of Southern America, Africa, and perhaps Asia. 
Cases of pernicious fever may differ entirely from any of the types given : 



INFECTIOUS DISEASES. 



209 



thus, furious epileptiform convulsions, or violent dyspnoea, or a wild 
delirium, or an overwhelming sweat with collapse, or sudden, frightful, 
cardialgic pains, ending in syncope and death, may be the outcome of a 
malignant malarial poisoning. 

Malarial Cachexia. — As the result of the continued ingestion of the 
poison in a malarious district, or of improper treatment, or of some pecu- 
liarity in the malarial germ which makes it with great difficulty respond 
to treatment, there may be developed the condition known as malarial 
cachexia, in which the chief symptoms are excessive anaemia and enlarge- 
ment of the spleen, often with pigment deposits, secondary atrophies, 
or other structural changes, in various internal organs. In the vast ma- 
jority of cases malarial cachexia is associated with irregularly recurring 
febrile paroxysms, but it is affirmed that it may exist without distinct 
paroxysm. It has been shown by Kelch that a single violent malarial 
paroxysm may cause a diminution of one million of red corpuscles per 
cubic millimetre ; and in malarial cachexia the proportion of red blood- 
corpuscles sometimes falls to five hundred thousand, instead of five mil- 
lion, in a cubic millimetre of blood. Headache, insomnia, anorexia, dys- 
pepsia, and various secondary symptoms are common, whilst hemorrhages 
from the mucous membranes and serous exudations into the subdermal 
cellular tissue, or into the pericardial and pleural or other cavities, are 
not infrequent. The liver is usually increased in size, but may be 
atrophic. Among the most important of the secondary diseases are 
nephritis, subacute or chronic, and chronic perilobular pneumonia. The 
enlarged spleen is usually firm and smooth to the touch, and may appar- 
ently fill up almost the whole abdominal cavity. 

Diagnosis. — The diagnosis of an ordinary malarial fever is easy, but 
in irregular malaria the symptoms may be misleading. If paroxysmal 
disturbances of any character recur at not very long intervals with show 
of regularity, malarial disease should be suspected, and an examination 
of the blood be made, or the effect of quinine be determined. If sufficient 
doses of quinine fail to influence the paroxysmal disturbance, the proba- 
bilities are altogether against such disturbance being of malarial origin. 
It has been affirmed by various practitioners that there are in the 
Southern United States malarial fevers of a continued type which are 
not arrested by quinine ; but the nature of such cases is doubtful, and 
further studies of the autumnal fevers of the South, with careful inves- 
tigations of the blood, are urgently needed at this time. 

The most common forms of paroxysmal fever simulating malaria are 
those of septicaemia and hepatic disease. In any doubtful case the final 
diagnosis must rest largely upon the finding or not finding of the malarial 
organisms. If there be no detectable organisms and no response to 
quinine, the case should be considered not malarial. In looking for 
malarial organisms, the most satisfactory results are obtained by direct 
examination of the fresh blood. A thin cover-glass, freshly cleaned with 

14 



210 



GENERAL DISEASES. 



nitric acid, then with alcohol, and finally with ether, receives a very 
small drop of "blood from the end of the finger or the lobule of the ear, 
and is placed upon a thoroughly cleaned glass slide. The blood will 
spread into a thin layer by the weight of the cover-glass, and should at 
once be examined with the aid of an oil-immersion lens. The parasites 
may be seen with a dry lens of high power, but satisfactory results are 
obtained only with the immersion lens. 

Staining of the organisms sometimes is advantageous. A small drop 
of blood is first allowed to spread out between two thoroughly cleaned 
cover-glasses, and these are then separated by sliding one from the other. 
After they have thoroughly dried, they are immersed in a mixture of 
equal parts of absolute alcohol and ether for half an hour. This fixes 
the blood firmly, and it may then be stained with methylene-blue and 
counterstained with eosin. Chezinski's mixture, composed of concen- 
trated aqueous solution of methylene-blue diluted with an equal quantity 
of water and twice the quantity of one-half per cent, solution of eosin in 
sixty per cent, alcohol, gives excellent results. The cover-glasses, after 
being fixed, are treated with the staining solution for several minutes, 
then washed off, dried, and mounted in balsam. The parasites are 
stained blue, the red corpuscles pink. 

Prognosis. — Malarial fever occurring in a previously healthy subject 
and in the central United States, if at once recognized and properly 
treated, never ends in death : it is always curable, provided the nature 
of the disease be recognized and appropriate treatment employed ; but it 
may be essential to remove the patient out of the malarious district in 
order to prevent perpetual reinfection. In tropical countries malarial 
diseases, especially if reinforced by continued exposure to the cause, may 
end fatally. 

Prophylaxis. — Although no prophylaxis will afford an absolute pro- 
tection from the malarial organism, much can be done by those who must 
expose themselves by obeying the following simple rules : first, avoid 
going out in the early morning or during the evening or night, especially 
when the weather is in any degree foggy ; second, sleep in the second or 
third story of the house ; third, take from five to ten grains of quinine 
either directly after breakfast or on going to bed at night. 

Treatment. — The ordinary paroxysm of intermittent fever requires 
no treatment, but the evening after its recognition the patient should 
take a foil dose of calomel and podophyllin, and in the morning from 
fifteen to twenty-five grains of quinine, so administered that the first 
dose shall be taken from eight to ten and the last dose from four to 
five hours before the expected recurrence of the paroxysm. The exact 
amount of quinine given should depend upon the known obstinacy of 
the malaria of the district. To the adult, in Philadelphia, twenty grains 
may be given ; farther south, thirty grains. The quinine should be re- 
peated the second day in somewhat smaller or larger dose according 



INFECTIOUS DISEASES. 



211 



to the effect of the first administration. The paroxysms having thus 
been broken, the patient should be put upon Fowler's solution, from 
three to six drops after meals, and no more quinine given until the 
seventh day, at which time the malarial paroxysm has a pronounced 
tendency to recur ; to prevent this recurrence, from fifteen to twenty- 
five grains of the alkaloid should be administered every seventh day 
for from four to six weeks. The quinine must be given in solution or 
in encapsulated powders, or in fresh pills of the bisulphate. Old sugar- 
coated pills of the sulphate are not trustworthy for prompt action. 

When the malarial paroxysm takes on an irregular form, brow ague, 
for example, larger doses of quinine are required to put it aside, so that 
from twenty-five to thirty-five grains should be given in the intervals and 
repeated in ascending doses until complete control is obtained. 

The treatment of a pernicious malarial paroxysm is a matter of the 
greatest importance. We have found that amyl nitrite will at once put 
an end to the chill in an ordinary malarial paroxysm without in any way 
interfering with the after- development of the fever and sweat. It is, 
therefore, probable that the drug will prove of service in the algid form 
of pernicious malaria in bringing about reaction. If the central tempera- 
ture during a pernicious chill be low, the hot bath should be used. When 
there is a distinct hyperpyrexia cold affusions may be practised, whilst 
at the same time external heat and mild sinapisms are freely used on the 
extremities. In the cases which we have seen there has been a heart- 
failure, which is to be met by the free hypodermic use of digitalis, 
strychnine, and cocaine. No time should be lost in producing a pro- 
found cinchonism, in the hope that by destroying the forming crop of 
parasites the length of the paroxysms will be diminished. If the stomach 
cannot be employed, a well-acidulated (tartaric acid) rectal injection 
of thirty grains of quinine bisulphate should be given, whilst ten to 
twenty grains of the bisulphate are given hypodermically. Two hours 
later, if relief has not come, the rectal injection should be repeated. 
At least seventy-five grains of quinine should be given within eighteen 
hours after the first coming on of the paroxysm, and cinchonism should be 
steadily maintained for a week, to be followed by the free use of Fowler's 
solution, with iron and other tonics, and the weekly doses of quinine. 

The successful treatment of chronic malaria is often one of great 
difficulty. The common method of continually giving quinine in moder- 
ate dose we believe to be bad : the patient is worried by the drug and the 
organisms are not scathed ; in our opinion it is much better to produce at 
intervals distinct cinchonism. Experience has shown that quinine has 
much more influence in these cases if given along with drugs which act 
upon the emunctories ; in some cases potassium bitartrate does good, 
whilst a bitter purgative, such as aloes, given daily for a length of time in 
such dose as will produce soft stools is often of the utmost service where 
there are pronounced hepatic congestion and enlargement ; mercurials, 



212 



GENERAL DISEASES. 



nitrohydrochloric acid, ammonium chloride, and other appropriate 
remedies (see Chronic Hepatitis) may be necessary before success can 
be expected. The arsenical preparations are especially valuable. In 
obstinate cases they should be given in such doses as to cause the slight- 
est puffiness of the face or albuminosity of the urine, then for a time with- 
drawn, and again given pro re nata. Iron with a simple bitter may be 
administered as freely as the stomach will bear. Removal from the mal- 
arial district is often essential. It is a popular belief, whose correctness 
we have confirmed by observation, that going into a high mountainous 
country will bring out a malaria which has remained latent, — an indica- 
tion that local deposits of the organism are formed in the body. Short 
but vigorous courses of quinine and of arsenic should therefore be given 
from time to time to persons who have suffered from malarial cachexia, 
even if the symptoms are not active. In bad cases of malarial anaemia it 
may be essential to put the patient to bed, and even sometimes to enforce 
a modified rest-cure. When there is enlargement of the spleen, iodine 
ointment may be used externally over the organ, whilst solid extract of 
ergot is given in full dose, from thirty to fifty grains a day, in capsules. 

DYSENTERY. 

Definition. — A specific disease, characterized by inflammation of 
the large intestine, associated with frequent, slimy, hemorrhagic stools 
and tenesmus. 

The term dysentery was originally applied to painful stools in contrast 
with diarrhoea, — frequent stools. The seat of the former was considered 
to be in the large intestine, that of the latter in the small intestine. In 
recent times research has been directed towards ascertaining the imme- 
diate cause of the dysentery, and has resulted in the recognition of a 
variety of exciting causes. 

Etiology. — It has long been known that dysentery is likely to occur 
in the form either of epidemics or of endemics, and as sporadic cases. 
Epidemics occur particularly among collections of individuals living in 
close quarters, as in camps, barracks, or institutions. The disease is 
especially likely to occur when the surroundings are insanitary, partic- 
ularly where there is exposure to cold and wet, insufficient or improper 
food, contaminated drinking-water, and depressing or exhausting mental, 
moral, or physical influences. Of persons exposed to such influences, 
those enfeebled by disease or excesses are chiefly liable. Dysentery is 
more likely to prevail during hot damp weather, as in the summer or 
the fall. The conditions of its origin have been found to be especially 
prevalent in malarial regions, and the exciting cause or causes are 
likely to be found in drinking-water, the injurious effects of which are 
enhanced by contamination with the dejections of persons already af- 
fected. The disease occurs in all parts of the world, and the variety 
found in tropical regions has received the term tropical dysentery. It is 



INFECTIOUS DISEASES. 



213 



probable that most of the cases of dysentery seen in the tropics, whether 
endemic or sporadic, are due chiefly to the presence of an intestinal 
parasite, the amoeba dysenterke. The occurrence of amoebae in dysenteric 
stools was first announced by Losch, and Koch found them in the tissues 
at the base of the intestinal ulcers and in the capillaries of the liver in 
the vicinity of hepatic abscesses occurring in dysentery. Osier first in 
America described their presence in dysenteric abscesses, and numerous 
observers have since confirmed this observation. Amoebae, however, are 
to be found in the colon in a variety of diseases, and even in health, and 
may not present any morphological characteristics by which they are to 
be distinguished from amoebae found in dysentery. The latter amoebae, 
as shown by Kartulis, are distinguished by being pathogenic in cats. 

Epidemics, endemics, and sporadic cases of dysentery arising in the 
temperate zones are usually attributed to bacteria, and it is also proba- 
ble that the progress of tropical dysentery is favored or influenced by 
their presence. There is no agreement as to the existence of specific 
bacteria in the production of dysentery, although several observers have 
described the occurrence of unusually minute bacilli differing from those 
found in other intestinal affections. 

Morbid Anatomy. — The anatomical changes found in dysentery do 
not differ from those present in inflammation of the large intestine 
due to other causes than those specifically concerned in the production 
of this disease. A catarrhal, follicular, diphtheritic, or gangrenous in- 
flammation of the large intestine may occur in a variety of diseases, as 
cholera, typhoid fever, scarlet fever, and small- pox, in which affections 
the intestinal inflammation is to be regarded as a complication of the 
disease in which it occurs. A diphtheritic colitis may result even from 
mercurial poisoning or be due to uraemia. 

The lesions are usually confined to the large intestine, increasing in 
severity from above downward. The most extreme alterations are more 
frequently found in the lower portion, especially in the rectum, and in 
exceptional instances the morbid changes may extend into the lower 
part of the small intestine. In the same case milder and more severe 
lesions may coexist. In catarrhal inflammation the mucous membrane 
of the colon and rectum is swollen and injected, whilst punctate hemor- 
rhages are frequent. The surface is besmeared with a viscid slime, in 
which epithelium, blood, or pus may be present. The submucous tis- 
sue is swollen, and often forms irregular thickenings, partly from oedema 
and partly from cellular infiltration. The solitary follicles are often en- 
larged through cellular hyperplasia, and are surrounded by a border of 
injected vessels. If a predominant enlargement of these follicles exists 
they may serve as the source of abscesses, which discharge into the in- 
testine and cause ulcers. These increase in size and coalesce, and the 
mucous membrane becomes extensively undermined. To this condition 
the term follicular inflammation is applied. 



214 



GENERAL DISEASES. 



A diphtheritic inflammation is indicated by the presence of bran-like 
spots or patches, the former often seated over hyperplastic follicles, the 
latter frequently first seen in the flexures of the large intestine and over 
the transverse and longitudinal bands which form the dividing lines 
between the pouches of the colon. The latter localization is explained 
by Yirchow as the result of the mechanical action of faecal masses upon 
the affected portions of the intestine. These patches represent super- 
ficial necroses of the mucous membrane, tending to spread in all direc- 
tions, and eventually covering the entire wall of the intestine. They 
become discolored by intestinal contents, especially by bile and blood- 
pigment, and assume a dark green or greenish-brown color. These 
necrotic patches become gangrenous, and are then detached as small or 
large sloughs, sometimes causing profuse hemorrhage and more or less 
extensive ulceration of the mucous membrane. The submucous tissue 
becomes swollen, the muscular coat ©edematous, and the inflammatory 
process may extend to the serous coat, the peritoneal surface of which 
is injected, hemorrhagic, and covered with fibrin. The mesocolon may 
also become infiltrated with inflammatory exudation, forming a brawny 
mass in which abscesses may arise, discharging into the intestine or 
breaking through the peritoneum and producing peritonitis. The mes- 
enteric glands in the vicinity of the inflamed mucous membrane are 
hyperplastic and injected, and may become necrotic and softened. 

Councilman and Lafleur have recently described in detail the alter- 
ations which occur in amcebie dysentery. These essentially represent an 
ulceration of the mucous membrane due to the presence of amoebae in 
the deeper layers of the mucous membrane. An infiltration of the sub- 
mucous tissue occurs, resulting in necrosis and softening of the overlying 
mucous membrane and the production of ulcers with overhanging edges 
and tending to become confluent. Amoebse are present in the infiltrated 
patches and at the base of these ulcers. If purulent inflammation is 
present it is regarded as the result of a complicating bacterial invasion. 

The catarrhal and diphtheritic inflammations of the intestine may 
cease at an early stage with the production of little or no destruction of 
the mucous membrane ; but with the formation of ulcers, whatever may 
be their origin, the inflammatory process tends to become chronic. More 
or less extensive destruction of the mucous membrane exists, portions of 
which may remain as bridges or as projecting masses forming pseudo- 
polypi. A fibrous thickening of the remaining intestinal wall may result, 
with the production of induration or stricture, and the outlet of the 
glands may be obstructed and multiple cysts be present in the atrophied 
mucous membrane. 

Abscess of the liver is a frequent complication of the severer varieties 
of dysentery, whether of amoebic or bacterial origin, although relatively 
more frequent in the former. Councilman has shown that the amoebic 
abscesses are probably due to the direct invasion of the liver by the 



INFECTIOUS DISEASES. 



215 



parasite, which may produce necrosis, softening, and liquefaction of the 
tissues without associated suppuration. If pus is also present in such 
amoebic necroses of the liver, it is attributed to the associated presence 
of pyogenic bacteria. True abscesses of the liver occur in other varieties 
of dysentery, and are regarded as the result of emboli from softened 
thrombi in the intestinal wall or from the continuous extension of a 
mesenteric thrombo-phlebitis from the inflamed intestine into the liver. 
The hepatic abscesses are often multiple, although tending to become 
confluent, and frequently perforate the diaphragm, when the pus is dis- 
charged through the lung. The further history of such abscesses is 
described in the section on suppurative hepatitis. 

Among the other occasional complications of dysentery are abscesses 
in remote parts of the body, suppurative inflammation of the serous cavi- 
ties and joints, and endocarditis. Noteworthy possible complications 
of chronic dysentery are parenchymatous degeneration of the kidneys, 
amyloid degeneration of the spleen, liver, and kidneys, and dropsy. 

Symptoms. — The characteristic symptoms of dysentery may develop 
suddenly or be preceded by an interval of several days of disturbed di- 
gestion, associated with chilly sensations, slight fever, and mild diarrhoea. 
Nausea and vomiting may also occur. Tenesmus and the peculiar stools 
then make their appearance. The former gradually increases in severity, 
and may be associated with vesical tenesmus, and the pain may extend 
into the testes. Frequent attempts, sometimes three or four an hour, are 
made to empty the bowel, often with the passage of but a small amount 
of liquid and not affording much relief. Abdominal pain and tender- 
ness, especially in the region of the sigmoid flexure and in the course of 
the colon, are frequent, usually immediately preceding the evacuation of 
the bowels. 

At the outset the stools consist of liquid faeces, but soon they take the 
form of a slimy fluid in which bits of faecal matter resembling chopped 
spinach appear. Such stools are the smaller in quantity the more fre- 
quent their evacuation. The dejections then become mixed with blood, 
resulting in the presence of a red, gelatinous substance without faecal 
odor, in which specks or clots of blood may be present. The gelatinous 
material may be in clumps, like boiled sago, and the abundantly hemor- 
rhagic stools may be watery, resembling beef -juice. With the progress 
of the inflammation opaque-yellow streaks and clots indicate pus, and 
the greater their abundance the more probable is the existence of ulcers. 
The presence of the latter is further made evident by the appearance 
in the stools of shreds of tissue. In the milder cases in the course of 
a few or several days the stools become more faecal and less frequent. 
The tenesmus diminishes and disappears. The appetite and strength 
return. In the severer cases the stools may become very offensive, the 
tongue dry and cracked, the pulse feeble, the temperature moderately 
elevated, perhaps subnormal, and in the severest cases there may be 



216 



GENERAL DISEASES. 



irregular chills and fever, profuse sweating, inflammation of the joints, 
and endocarditis. Paralysis sometimes results, due to a peripheral neu- 
ritis. In such cases a long period of convalescence exists. 

The symptoms of amoebic dysentery closely resemble those of other 
varieties of this disease. The course, however, is more irregular, with 
frequent remissions and exacerbations. Abdominal pain and tenesmus 
are less frequent and severe, and the stools, though of similar gross ap- 
pearances, are less frequent and more copious. The presence of amoebae 
is their especial characteristic. They are to be found, especially in the 
blood-stained mucus, as motive masses of protoplasm, especially active in 
alkaline stools, five or six times as large as red blood- corpuscles, and not 
infrequently containing the latter within their substance. Periods of con- 
stipation may alternate with those of diarrhoea. Even in the milder cases 
the course is protracted over several weeks, and the patient becomes 
anaemic, weak, and thin. 

Any variety of dysentery may assume the chronic form, of which the 
principal symptom is diarrhoea. The stools are composed largely of lique- 
fied faeces in which gelatinous particles may be present, but without blood 
and with relatively little slimy material. Tenesmus and abdominal pain 
are infrequent. Chronic dysentery may extend over a period of years, 
during which time there may be intervals of comparative comfort and 
well-being alternating with exacerbations, in which the acute symptoms 
already mentioned may return. Usually a normal appetite and undis- 
turbed gastric digestion enable the patient to resist the debilitating effects 
of the disease, although the longer it persists and the more frequent the 
exacerbations the greater the loss of flesh and strength. 

Diagnosis. — Dysentery is to be diagnosticated by the presence of 
characteristic stools, tenesmus, and pain in the course of the large intes- 
tine. Bloody stools from hemorrhoids or rectal polypi occur without 
tenesmus, and a rectal examination will frequently permit the exclusion 
of tubercular, syphilitic, or cancerous ulcers of the rectum, a source of 
rectal pain, if not of tenesmus. Amoebic dysentery is to be recognized 
by the discovery of motive amoebae in the stools. Chronic dysentery is 
to be recognized by the persistence of diarrhoea, the frequent presence in 
the stools of sago-like grains, and the occasional presence of pus or blood. 
The discovery of amoebae in the stools of chronic diarrhoea is evidence of 
the limitation of the inflammation to the large intestine, as well as of its 
nature. 

Prognosis. — The mortality in dysentery varies in accordance with the 
circumstances of its development. The milder cases terminate favor- 
ably in a fortnight. The severer cases extend over a period of several 
months, while chronic dysentery may be continued over a period of years. 
Epidemics in armies may show a mortality of fifty per cent, and upward, 
while the average fatality in endemics may not exceed ten per cent. In 
recent years the mortality among English soldiers in India and in Egypt, 



INFECTIOUS DISEASES. 



217 



suffering largely from amoebic dysentery, has ranged from one per cent, 
to five per cent. The prognosis is more serious in persons enfeebled by 
age, disease, or intemperance. Unfavorable signs are copious, bloody, 
and offensive, putrid stools, abscess of the liver, peritonitis, and arthritis. 
The ultimate prognosis of chronic dysentery is grave from the liability to 
recurrences, the tendency to eventual emaciation and debility, and the 
occasional occurrence of amyloid degeneration or intestinal obstruction. 

Treatment. — For the purposes of therapeutic discussion dysentery 
may be divided into the mild epidemic or sporadic form, the disease com- 
monly seen in the Northern United States and similar temperate zones, 
tropical dysentery, and the typhoid dysentery of camps and other crowded 
places. The subject may be further divided into the hygienic treatment, 
the general medical treatment, and the local treatment. Experience 
seems to show that, whilst general medical treatment varies, the hygienic 
and the local treatment are the same for all forms of the disease. 

Every case, even apparently the simplest, of dysentery should be 
looked upon as a serious disease, and the patient put at once to bed upon 
rigid diet. Strict disinfection of the faecal passages should also be en- 
forced as in typhoid fever. 

In mild cases warm milk, rice, milk toast, and barley gruel may be 
allowed. In severe cases animal broths, including chicken jelly, should 
make up the whole dietary, or perhaps be supplemented by the care- 
ful use of raw eggs or of milk. Whenever milk is used care should be 
exercised to prevent the formation of large curds in the gastro-intes- 
tinal tract. An ounce of lime water should be added to every eight 
ounces of milk, or the milk should be partially predigested. It should 
be taken in moderate quantities at short intervals (two to three hours), 
and drunk slowly. No spice or condiments should be allowed, and even 
salt must be used with great moderation. As convalescence progresses 
and the diet is increased, white meat of chicken, sweetbreads, lamb, and 
other tender, easily digested meats are to be preferred to starchy, sac- 
charine, or vegetable foods. Pulled bread* or thoroughly toasted stale 
bread should be the first starchy food allowed. 

In the mildest cases of ordinary dysentery a single large dose of castor 
oil with a little opium may be administered with immediate relief. In 
the more severe cases the choice is between the mercurial and the saline 
treatment. We prefer to give one- quarter grain of calomel with one 
grain of ipecacuanha every one, two, or three hours, pro re nata, reducing 
the ipecacuanha if nausea be produced, until large, bilious passages are 
obtained. In accordance with the saline method, one drachm of Epsom 
or Glauber's salt may be administered every three hours until free pur- 



* "Pulled bread," a very useful article of diet, is made by cutting an ordinary 
loaf in half, pulling out of the soft part with the fingers long pieces, two or three 
inches thick, and rebaking them for fifteen minutes in a very hot oven. 



218 



GENERAL DISEASES. 



gation results. Usually relief follows the action of these remedies, aided 
by local treatment. If it do not, salol (five grains) and bismuth (fifteen 
grains) may be administered every three hours, the saline or other laxa- 
tives being repeated from time to time if the passages tend to return to 
their original character. In a very obstinate case the ipecacuanha treat- 
ment should be tried. 

Tropical dysentery is best treated with ipecacuanha given in large 
dose. Vomiting is almost always produced, but, according to our ex- 
perience, is to be avoided as much as possible, although many tropical 
practitioners prefer to begin treatment with a powder of thirty grains of 
ipecacuanha. Our method is to give one-sixth grain of extract of opium, 
followed in fifteen minutes with from five to ten grains of ipecacuanha in 
capsulated pill, this being repeated every two or three hours, according 
to the urgency of the case, until absolute intolerance by the stomach 
of the drug is produced, or large, usually blackish, discharges from the 
bowels take place. These are almost invariably followed by relief. 

In the treatment of any form of dysentery, astringents, fall doses of 
opium, and all other remedies of a constipating character are to be abso- 
lutely avoided. In camp or adynamic dysentery the ipecacuanha treat- 
ment is probably, on the whole, the most successful, but in many cases 
the adynamia is so extreme that support and stimulants are essential. 
"No more alcohol, however, should be given than is necessary Strych- 
nine is especially valuable. In this, as in other forms of the disease, if 
the temperature rises above 103° F. , cold applications are of service, and 
even cold baths should be used. 

In all forms of acute dysentery the local treatment is exceedingly im- 
portant. In robust, severely attacked individuals leeching around the 
anus may sometimes be practised. Counter-irritation over the abdomen 
is of service, but should be of such mild type (spice plasters, mustard 
poultices, 1 to 8) that it can be steadily maintained hour after hour. 
In the height of the disease great relief, and even permanent good, are 
often effected by ice suppositories (small pieces of ice shaped like an 
ordinary suppository), inserted for a length of time, one after another, 
as fast as they melt. These may be supplemented by large injections 
of ice-cold water given at short intervals, or of hot salt solution. The 
tenesmus may be largely controlled by opium and belladonna supposi- 
tories, but, as these by drying up secretion may be harmful, they should 
be used as sparingly as possible. In many cases, after the local use of 
cold, continuing relief can be obtained by suppositories of iodoform, three 
grains each. Disinfection of the large intestine by means of large injec- 
tions containing bismuth, salol, or silver nitrate, theoretically should afford 
brilliant results. Bismuth we have tried with good results ; but with 
salol and the silver salts we have had no experience in the acute disorder. 
In all cases the parts about the anus should be well washed and greased 
(vaseline or cold cream) after each passage, to prevent excoriation. 



INFECTIOUS DISEASES. 



219 



In the treatment of chronic dysentery a heavy woollen abdominal band- 
age should be worn day and night. The diet should be rigidly restricted 
to milk 7 strong animal broths, tender meats (except pork, veal, tame 
turkey, ducks, and geese), pulled bread, and toast. Substances contain- 
ing tannic acid, lead preparations, camphor, and other astringent reme- 
dies should be absolutely avoided, unless the discharges become so 
frequent and severe that they must be checked to save the general 
strength. Even under these circumstances it should be recognized that 
the astringents increase the local disease. Of these astringents lead is 
probably the least harmful. Salol and bismuth preparations are often of 
service if given in very large doses one and a half hours after eating, — 
i.e. , at a time when the food is flowing towards the large intestine, which 
they must reach to be of service. Silver nitrate given by the mouth is 
probably of little value, because of its certain early decomposition. The 
chief reliance for cure must be upon the local treatment by means of large 
enemata, which should fill the whole colon. The milder local remedies, 
such as bismuth and resorcin, may in this way be brought in direct con- 
tact with the mucous membrane. Most brilliant results have in our hands 
been obtained by large injections of silver nitrate (from thirty to sixty 
grains) in two quarts of water. We have never seen any constitutional 
or severe local symptoms produced by these large doses. The injection 
usually is expelled in from three to five minutes. In giving it, however, 
the practitioner should always have at hand a saturated solution of ordi- 
nary salt, and if the bowel fail in a few minutes to discharge its contents 
he should decompose the excess of silver by using its chemical antidote. 
In giving the injection the patient should lie upon the back, with the legs 
drawn up and the hips so placed upon a hard pillow as to elevate the 
pelvis. The rectal tube should then be inserted five to six inches, and by 
means of the fountain syringe the fluid allowed to flow in without force. 

In some cases of chronic dysentery entire change of life is essential ; 
and when there have been wide-spread ulceration and destruction of the 
mucous membrane through the disease-processes of years, cure is hopeless. 

CHOLERA. CHOLERA ASIATICA. 

Definition. — A contagious disease, produced by the comma bacillus 
of Koch, and characterized by violent serous purging, rapidly followed 
by collapse. 

Etiology. — Asiatic cholera is endemic in India, whence reports of its 
existence appeared in European literature as early as the sixteenth cen- 
tury, whilst a good description of it was given by Bontius in 1629. It 
always exists in India ; indeed, apparently it is the chief instrumentality 
in keeping down the surplus population, having, according to Annesley, 
between 1817 and 1840 destroyed eighteen millions of Hindoos. Cholera 
first started on its great world-travels in 1817 and 1818, reaching China 
in 1821, and in 1823 the borders of Europe, where it ceased for the 



220 



GENERAL DISEASES. 



time to progress. In 1830 it invaded the Crimea by the route of the 
Caspian ; in 1831 it reached Hamburg, in 1832 London and Calais, and 
the same year, through Quebec and New York, it invaded the American 
continent, where there were local recurrences of the disease as late as 
1835 and 1836. In 1844 cholera again set out upon its march by the route 
of Persia and the Caspian Sea, reaching St. Petersburg, Hamburg, and 
the French seaports in 1848, and entering the United States the same 
year through New Orleans, spreading up the valley of the Mississippi as it 
had in 1842 travelled down that watercourse. In 1851 partial outbreaks 
occurred in Europe, and in 1854 the disease reappeared in New York and 
widely travelled through the United States. In 1865 a new cholera wave 
entered Europe through Arabia, rapidly spreading to the seaports of the 
Mediterranean, and reaching the United States in 1866. In 1873 a few 
cases appeared in the United States, and in 1884, and again in 1892 and 
1893, European epidemics sent scattered cases to the United States, 
which, however, by careful sanitation were prevented from becoming the 
centres of serious outbreaks. 

In all these epidemics the route of the disease was along great lines 
of travel. Not only did the disease-wave follow watercourses, but rail- 
roads and caravan routes ; over oceans and seas, through valleys, over 
water-sheds, across deserts, the cholera passed along with its human 
prey. The yearly pilgrimage of Mohammedan devotees to Mecca still 
remains a permanent menace to the civilized world. 

In 1884 Koch discovered the cause of cholera, an actively motile, 
flagellate, curved bacillus, the "comma bacillus," which is about half 
the length of the bacillus of tuberculosis and is considerably thicker, 
and which under certain conditions forms long, winding, spiral fibres, 
and hence is a spirillum. According to the observations of Hueppe, 
frequently two small, spherical bodies form in the spiral threads and 
continue to increase in number until the whole thread is resolved into 
minute round cells, cohering by a jelly. These so-called "arthro- 
spores" resist desiccation and other injurious influences much better 
than does the comma bacillus, and under favorable circumstances de- 
velop into the comma bacillus. They appear, therefore, to be a per- 
manent form of the cholera organism, and it is probably largely through 
their influence that the disease is spread. The cholera organism de- 
velops rapidly in sterilized water, in milk, and in various organic solu- 
tions, provided these be not acid. It is easily destroyed by various 
bacteria, by acids, by germicides, and by a temperature of 130° F. It 
exists in immense quantities in the alvine discharges of cholera patients, 
and has been detected in drinking-water, milk, and various foods. Dogs 
and guinea-pigs fed upon this bacillus do not suffer unless they are so 
fed and medicated as to overcome the excessive natural acidity of the 
gastro-intestinal juices, when the cholera bacillus is capable of causing 
in them death preceded by cholera-like symptoms and lesions. The 



INFECTIOUS DISEASES. 



221 



comma bacilli are never found in the blood or general tissues, although, 
they enter the epithelial cells and basement membranes of the intes- 
tine. As the comma bacillus exists in the human body only in the 
primse vise, escapes from the human body only with the alvine dis- 
charges, and is incapable of producing cholera when injected hypo- 
dermically, infection must take place through the mouth. For such 
infection it is necessary for drinking-water, food, or other medium of 
transmission to become contaminated, directly or indirectly, with the 
alvine discharges. 

The exact relation of the spores to the genesis of the disease is uncer- 
tain. Pettenkofer believes that it is necessary for the cholera poison to 
undergo further development in an appropriate soil before it can acquire 
fresh pathogenic potency, basing his belief upon the fact that the disease 
is very rare on shipboard, and that certain places, such as Munich, situ- 
ated on rocky soil, enjoy immunity. A porous soil with high ground- 
water and much organic matter certainly does seem to favor the develop- 
ment and diffusion of the cholera bacillus. Whether under these cir- 
cumstances the spores form and multiply in the soil is not known. 

Morbid Anatomy. — The appearances vary somewhat as death occurs 
early or late in the disease. In the former case rigor mortis is unusually 
pronounced and prolonged. Granular degeneration of the heart, liver, 
and kidneys is present. The pleurae, pericardium, and peritoneum are 
besmeared with a viscid fluid, and sometimes show hemorrhagic patches. 
The spleen is but little altered. The principal changes are to be found 
in the intestine and in the liver. The former contains more or less 
rice-water material, and the mucous membrane, especially of the small 
intestine, is injected and swollen, and of a velvety appearance from 
enlargement of the villi. The solitary follicles and Peyer's patches are 
enlarged, and the latter may present a sieve-like appearance from macer- 
ation and exfoliation of the superficial epithelium. The mesenteric 
glands also may be swollen, injected, and soft. The kidneys are pale, 
and the epithelium of the convoluted tubules is necrotic and disinte- 
grated. The mucous membrane of the uterus is often injected ; its 
cavity contains more or less bloody material. If death occurs at a later 
stage of the disease, rigor mortis is less extreme. Hypostatic oedema 
and injection of the lungs are frequent. The appearances of the intes- 
tine are like those above described, but less extreme. There is fatty 
degeneration of the epithelium of the convoluted tubules of the kidney. 

Symptomatology. — The incubation period of cholera appears to vary 
from a few hours to as many days. The first symptom is a diarrhoea, 
which is usually not accompanied by pain, but with much borborygmus 
and a constantly increasing serosity of the stools. With this there are 
usually general malaise and loss of appetite, but no febrile reaction. In 
some cases there is epigastric and even severe abdominal pain. After 
from a few hours to six days the second period of the disease may be 

i 



222 



GENERAL DISEASES. 



considered to be entered upon. In this the dejections are extremely 
frequent and profuse, free from fsecal odor, and almost colorless, having 
floating through them epithelial debris, the whole resembling rice-water. 
During this period there are also increasing vomiting of rice-water liquid, 
excessive thirst, violent abdominal pain and cramp, and finally agonizing 
cramps in the extremities. The pulse is small and frequent, the bodily 
temperature lowered, the surface cold. This period may last from one 
to two days. 

In favorable cases the stools become less frequent and smaller, the 
cramps disappear, and gradually the patient recovers. In unfavorable 
cases the subject passes into the so-called algid period ; the passages 
may be less abundant and less frequent, or may even cease, but extreme 
headache, suppressed or whispering voice, intense anxiety, vomiting, 
cramps in the extremities, great fall in the temperature of the surface, 
and especially of the feet and hands, a progressive failure of oxygenation 
of the blood so that the skin becomes more and more cyanosed until the 
nails are black, a disappearing pulse, and suppression of the renal secre- 
tion, — these make up a series of symptoms which end in complete col- 
lapse, sometimes associated with coma, more frequently with a peculiar 
condition of consciousness in which there is entire indifference as to 
the result. Although the surface of the body and of the extremities is 
uniformly cold, the rectal temperature varies ; it may be normal, slightly 
elevated, or depressed. In three-fourths of the cases death occurs during 
the period of algidity. 

When amelioration takes place, the cyanosis disappears, the skin be- 
comes warm, the urine increases in quantity, the pulse regains its force, 
the respiration becomes regular, and the cramps diminish, and so by a 
steady progress convalescence is reached in from ten to fifteen days. ~Not 
rarely this period of reaction is less favorable ; the anuria may persist, 
or more frequently typhoid symptoms may develop. In rather rare cases 
distinct fever, epistaxis, and even bilious diarrhoea appear. In another 
set of cases the symptoms of the period of reaction resemble those of 
meningo-encephalitis, with fever, excessive agitation, violent headache, 
irregular, convulsive movements, bounding pulse, and usually after one 
or two days death in coma. Eecovery, however, is possible, even when 
the symptoms have seemed hopeless. 

Various cutaneous eruptions, as urticaria, erythema, or roseola, de- 
velop during the period of reaction in about four per cent, of the cases. 
More serious are the pneumonias and other pulmonic complications, which 
are not rare. Convalescence is usually protracted, and almost always 
accompanied by dyspepsia and often by rebellious diarrhoea. Neuritis, 
tetany, especially after childbirth, furunculosis, and glycosuria, are among 
the sequelae which occasionally occur. 

The mildest forms of cholera are those which are known as cholerine, 
in which the only symptom is a slight diarrhoea ; the most severe forms, 
♦ 



INFECTIOUS DISEASES. 



223 



those in which there is an abrupt development of great bodily weakness 
with vertigo, followed in a very few hours by fatal collapse, which may be 
preceded by a violent intestinal flux, or in certain cases {cholera sicca) by 
a paralysis of the intestines which causes retention of the secretions, so 
that, although nothing has come from the body during life, after death 
the bowels are found full of rice-water liquid. Between the two extremes 
every grade exists. 

Diagnosis. — During an epidemic of cholera every case of serous 
diarrhoea should be considered as one of cholera, and so treated with the 
utmost care. So far as the symptoms are concerned, there is no difference 
between cholera, cholera nostras, and various metallic poisonings, notably 
the antimonial and the arsenical. The finding of the comma bacillus is 
the only complete demonstration that a case is or has been one of Asiatic 
cholera ; for even the lesions found after death from one of the diseases 
which simulate cholera may be indistinguishable from those of that 
disease. 

Prognosis. — In the beginning of an epidemic of cholera the mortality 
usually ranges from forty to sixty or even seventy per cent., but as the 
epidemic progresses, either because the pathogenic agent loses its viru- 
lence or because it is the most susceptible who are first attacked, the 
fatality steadily diminishes. In individual cases the prognosis must 
always be guarded, since the mildest diarrhoea may suddenly develop 
an irresistible force, whilst, on the other hand, it is not rare for patients 
to react from the most desperate conditions. During the period of reac- 
tion any irregularity of symptoms or any appearance of cerebral or pul- 
monary complications is of the gravest import. The very young, the 
very old, the alcoholic, the insane, and persons weakened by previous 
chronic disease, all die from cholera in extraordinary proportion. 

Prophylaxis. — From the nature and life-history of the cause of 
cholera, it is evident that absolute shutting out of the germ by quarantine 
will suffice to prevent the spread of the disease. What is theoretically 
easy, however, is in many cases practically impossible ; but whenever 
an isolated case does enter an unaffected district, the utmost vigilance 
should be exercised to see that all the faecal discharges are thoroughly 
disinfected, and that all body- or bed-linen and every garment with 
which they may have come in contact are either destroyed or disin- 
fected beyond question. Absolute cleanliness will aid in arresting the 
spread of cholera, but will not atone for carelessness in allowing the 
escape of the germ. In no other disease is personal prophylaxis so 
effective as in cholera. For personal infection it is necessary that the 
germ be taken into the mouth and into the stomach, so that theoreti- 
cally it is possible to live in daily contact with cholera patients without 
evil result. 

The precautions must be absolute in their rigor : weakness in a single 
link or particular may do away with the value of the whole procedure. 



224 



GENERAL DISEASES. 



The hands must be frequently and thoroughly washed and disinfected, 
especially after handling the sick or the bed- clothing from them. The 
food must be taken directly after it has been disinfected by fire ; the diet, 
therefore, must be restricted to meats, hot bread, cakes, or toast, and such 
other articles as shall come from the fire directly to the table, and be 
eaten as hot as can be borne by the palate. It is, of course, essential 
to avoid all indigestible food and everything tending to produce gastro- 
intestinal catarrh, as this condition of the alimentary canal would greatly 
favor the development of a stray germ which might break through the 
cordon of defence. No water should be taken except that which has 
been well boiled and is still hot, or that which has been immediately 
taken out of bottles into which it was put before the epidemic. It is 
also essential that the dishes for food and drink immediately before using 
be heated to such a temperature as to destroy any adhering germs. 
Some years ago a violent outbreak of cholera in the Insane Department 
of the Philadelphia Almshouse was arrested within twelve hours, without 
the precautions just spoken of, by the free administration of sulphuric 
acid lemonade. The only new case was that of a man who refused the 
prophylactic. In the surgical wards of the same institution the acid was 
used from the beginning of the epidemic, and in these wards, although in 
no way isolated from the other departments, there was absolute freedom 
from the disease. It has been experimentally proved that in dogs and 
guinea-pigs susceptibility to the cholera germ can be produced by render- 
ing their highly acid stomachs alkaline, and there is reason for believing 
that it is possible to render the human primse viae an unfavorable habitat 
for the cholera bacillus by making them abnormally acid. 

Treatment. — During an epidemic of cholera it is essential that every 
case of diarrhoea be treated with the utmost care, and it is certain that 
many cases of the disease may be thus arrested before the cholera bacillus 
has full possession of the intestinal tract. The patient should be put to 
bed, and the diet confined to strong broths and meat- essences, whilst such 
doses of aromatic sulphuric acid or the aromatic sulphuric acid diar- 
rhoea mixture as may be necessary should be given. In some cases it 
would probably be of great service to wash out the large intestine thor- 
oughly with distinctly acidulated water. Hayem recommends lactic acid, 
five drachms in twenty -four hours, in cholera, or, as a prophylactic, a 
drachm and a half daily well diluted. The dilute or aromatic sulphuric 
acid has the advantage of astringency : two drachms of it may be given in 
the twenty-four hours without any unpleasant effects. Naphtol, strontium 
salicylate, bismuth subnitrate, and other intestinal antiseptics should be 
freely used. Opium suppositories should be given pro re nata, especially 
when there is vomiting. Bismuth salicylate is particularly commended 
by some French authors, and may be efficacious. 

The same treatment should be kept up during the second period of 
cholera. 



INFECTIOUS DISEASES. 



225 



During the algid stage of cholera the patient should be required to 
drink very freely of hot water, with or without the addition of small 
quantities of alcoholic stimulants, according as the water is made thereby 
more or less acceptable to the stomach. External heat should be freely 
applied to the extremities, or, if the temperature be below the norm, 
the whole body should be immersed in a bath of 105° F. As long ago 
as 1832 Lizars practised filling the large intestine with hot water during 
this stage, and the practice has recently been imitated with alleged ex- 
cellent results. Instead of the saline solution sometimes employed it 
might be better to use an acid solution for the purpose of destroying the 
cholera bacillus, and a solution of tannic acid has been especially com- 
mended. In 1832 Th. Latta strongly urged the use of intravenous injec- 
tions in the later stages of cholera, and their value seems to be estab- 
lished. They are apparently harmless, since Hayem has found that 
he could double the daily amount of blood in the dog by their means 
without producing any distress except a temporary irritation of the 
kidneys. Hayem 7 s formula consists of one thousand parts of distilled 
water with five parts of sodium chloride and ten parts of sodium sul- 
phate. We should prefer the saline solution without the sodium sul- 
phate. The injection may be slowly made into the saphenous vein by 
means of a fountain syringe, the greatest care being exercised to see 
that the injected liquid and the apparatus used have been absolutely 
sterilized by heat. There is commonly an immediate reaction, with re- 
lief of the urinary suppression, but in most cases the symptoms return 
in the course of a few hours, and, although two or even three injections 
may have been practised, the ultimate result is affected in only a few 
cases. Instead of throwing the solution into the vein, it may be injected 
into the cellular tissue of the buttock. A large quantity can be thus 
taken and rapidly absorbed. Moreover, the process can be repeated 
until the result is secured or the method proved inefficacious. 

During the stage of reaction symptoms should be v met as they arise. 
The diet should be the simplest and most non- irritating possible, and the 
recurrence of diarrhoea should be strenuously guarded against. 

CHOLERA NOSTRAS. CHOLERA MORBUS. 

This disease may be with propriety noted in this place because the 
symptoms may exactly counterfeit those of cholera, and because it has 
been maintained by Guerin and others that it is really the sporadic form 
of Asiatic cholera. The symptoms often develop with great suddenness, 
and consist of violent vomiting and serous diarrhoea, usually without 
pain, although there may be great abdominal distress. The stools, at first 
faecal, become more and more watery, until they may be undistinguishable 
from the rice-water stools of Asiatic cholera. In the severe cases there 
is great weakness, with whispering voice, rapid, small pulse, and cold, 
livid extremities, ending, it may be, in a fatal collapse. 

15 



226 



GENERAL DISEASES. 



Cholera morbus occurs exclusively in adults, or, to speak correctly, 
this acute serous diarrhoea occurring in adults is known as cholera mor- 
bus, in children as cholera infantum. It was affirmed in 1884 by Finkler 
and Prior that the disease is dependent upon a comma bacillus not to be 
distinguished from that of Asiatic cholera. It was, however, proved by 
Koch that the two organisms are distinct, and it is not certain that the 
bacillus of Finkler and Prior is the sole cause of cholera nostras. In 
three cases Gilbert and Girode have found the bacterium coli commune 
abundant in the stools. 

The most probable view is that cholera morbus is a serous diarrhoea 
which may be provoked by various causes. As at least one variety, 
cholera infantum, must be looked upon as a form of thermic fever, so 
some adult cases may be instances of neuro -paralytic diarrhoea produced 
by excessive heat. Again, cholera morbus, or at least the congeries of 
symptoms which bears that name, may be caused by various metallic 
poisons. Further, we have seen the symptoms of cholera morbus induced 
by violent emotion. 

Cholera nostras as it occurs among adults in this country is rarely 
fatal except in subjects who are weakened by previous disease or are of 
feeble constitution. It is best treated by the hourly administration of 
small doses, one-tenth of a grain, of calomel, with the free use of opium 
suppositories and of intestinal stimulants, such as camphor, the vola- 
tile oils, and chloroform. (See formula 9.) Abdominal mustard plasters 
should also be freely used. When there is fall of temperature the hot 
bath, when there is elevation of temperature the cold bath, should be 
employed. So soon as under the influence of calomel the passages be- 
come brownish the drug should be withdrawn. Convalescence usually 
follows at once. 

YELLOW FEVER. 

Definition. — An acute febrile disease, characterized by fever lasting 
from one to four days, followed by an intermission, with in severe cases 
a secondary exacerbation, a steady fall of the pulse, which commences 
during the period of fever, jaundice, a tendency to stasis of the cir- 
culation and to hemorrhage, and parenchymatous inflammations of the 
liver, kidneys, and stomach. 

Etiology. — The question of the contagiousness of yellow fever has 
been investigated and discussed most extensively, so that at present it 
seems established that the disease is incapable of passage directly from 
man to man, but that the poison, whatever its nature may be, passes from 
the sick into some favorable locality where it develops the activity which 
enables it to infect another person. For the growth and development of 
the poison outside of the body certain conditions are necessary : these 
conditions probably are, first, a steady well- maintained temperature ; 
second, the presence of filth. 

It has been a wide-spread belief that this filth must have at least some 



INFECTIOUS DISEASES. 



227 



animal matter in it, and that excrementitious material is especially fit for 
its development. It would seem that the most favorable conditions are 
the existence of high temperature and the presence of such mixed masses 
of vegetable and animal filth as prevail about seaports. The effect of 
cleanliness was strongly illustrated in the banishment of yellow fever 
from New Orleans by the rigid military sanitation enforced by General 
B. F. Butler during the civil war. The usual history of an epidemic 
is a dirty town, a single imported case, an outbreak of disease. In an 
instance reported by Guiteras, the man, moving from an infected dis- 
trict, had fever in his own house, which was kept clean, with no spread 
of the disease ; during early convalescence he went to another village 
and lived in a dirty room, which room became a source of infection 
for a number of cases. In another case the clothing of a sailor dying 
of the disease was packed in his chest and sent to his wife in New York ; 
two people were present at the opening of the chest, and were both 
infected. 

Numerous bacilli and other organisms have been found in the dis- 
charges and tissues of yellow fever patients, but we have no knowledge 
of the nature of the germ, which is generally believed to be, however, 
an animal organism, whose life-history comprises at least two different 
developmental stages, — one inside, one outside, the body. 

The countries which are infected by yellow fever are divided by 
Guiteras into — (1) the focal zone, in which the disease is practically en- 
demic ; (2) the perifocal zone, with periodic epidemics ; and (3) the zone 
of occasional epidemics. Number 1 includes the important seaports of 
Havana, Yera Cruz, Matanzas, Eio Janeiro, and a small portion of the 
Atlantic African coast. Number 2 comprises the African Atlantic coast, 
a few seaports of the American Pacific coast, and the majority of the 
subtropical Atlantic United States seaports, including New Orleans. 
Number 3 includes all countries bordering on the Atlantic Ocean 
between 45° north latitude and 35° south latitude, below an altitude 
of fifteen thousand feet, not included in numbers 1 and 2. The epi- 
demics habitually travel from the sea- coast along watercourses or along 
lines of railroad. 

Race characteristics have been believed to be dominant in the causa- 
tion of yellow fever ; it has been held that, although white races are 
extremely susceptible to the poison, the white inhabitants of Cuba 
and other places where the disease is endemic are incapable of taking- 
it. Guiteras, however, has shown that this is not because of inherited 
peculiarities, but because yellow fever is essentially a mild disease of 
childhood, and that in Cuba all the children have had attacks the 
nature of which has been heretofore unrecognized, but which have 
afforded protection in after-life. 

Morbid Anatomy. — The skin, subcutaneous tissues, and viscera are 
bile-stained. Large and small hemorrhages are frequent in the skin, in 



228 



GENERAL DISEASES. 



the gastro-intestinal and urinary mucous membranes, beneath the pleurae, 
pericardium, and peritoneum, and within the lungs. The stomach con- 
tains coffee-grounds material which is largely composed of blood- 
corpuscles and blood-pigment. The heart, liver, and kidneys show the 
appearances of more or less advanced parenchymatous degeneration. 
The muscular substance of the heart is granular or fatty ; in the latter 
case the myocardium is opaque yellow and flaccid. The liver is either 
enlarged or diminished in size, of an opaque yellow color, its cells gran- 
ular, fatty, or necrotic. The kidneys are enlarged from swelling of the 
cortex, the epithelium of which is also granular, fatty, and necrotic. 
The spleen is comparatively free from alterations, although sometimes 
unusually soft. 

Symptomatology. — The period of incubation varies from a few hours 
to fourteen days, although it is very rare for the disease to develop after 
the ninth day. In a Florida epidemic nine hundred unacclimated indi- 
viduals who had been exposed to the poison were quarantined for ten 
days and then went into healthy districts ; not one of them developed 
the disease after the discharge. The invasion, which occurs more fre- 
quently at night, is abrupt, with repeated chills, excruciating pains in 
the back, head, and limbs, and an immediate rise of temperature. Vom- 
iting is very common, and in some cases an exanthematous rash appears, 
especially in the scrotal region. There is usually an evening exacerba- 
tion of temperature on the first day, but on the second or third day 
(rarely even on the first) the characteristic fall of temperature begins 
and continues, though sometimes interrupted by evening exacerbations 
until it reaches the norm from the second to the fourth day. 

During the whole period of the fever there are great anxiety, restless- 
ness, intense suffering, and not rarely delfrium, varying in degree from 
slight mental confusion to wild mania ; in some cases there is stupor. 
When the remission occurs not only does the fever subside, but the 
pains usually disappear ; the mind becomes clear, and not infrequently 
all anxiety is lost ; there remains, however, an increasing epigastric 
tenderness, with continuing and increasing slowness of the pulse, per- 
chance a little heaviness ; soon jaundice appears, first generally in the 
forehead and conjunctiva, and rapidly increases until the whole surface is 
dark yellow and the deep-brown urine is heavily loaded with biliary 
constituents. 

The period of remission may end in convalescence, but commonly 
there is developed a second paroxysm of fever with well-marked diurnal 
remissions, and sometimes hyperpyrexia. Even during the remission the 
failure of strength is usually marked, but in the fever of reaction, as it 
is called, the adynamic symptoms become more pronounced. Death 
may occur during the secondary fever, or, after a prolonged, irregular 
course, by gradual abatement of symptoms the patient may pass into 
convalescence. 



INFECTIOUS DISEASES. 



229 



In severe cases the jaundice deepens until the whole surface is uni- 
formly bronzed. The vomiting recurs, and becomes uncontrollable, 
whilst brownish or blackish flakes appear in the matter ejected and in- 
crease in number until the whole fluid is black and opaque. The capil- 
lary circulation becomes so nearly stagnant that the dependent and 
extreme portions of the body, fingers, toes, scrotum, back, etc., are deep 
purplish. The pulse grows more feeble and irregular. The urine lessens 
in quantity, and may be completely suppressed. Hemorrhages occur 
from the various mucous membranes, even from the gums. Petechia^ 
vibices, hematuria, bloody stools, and an intense apathy mark the com- 
plete degradation of the blood and the failure of the vital power, which 
deepens until a quiet death results. 

Whilst the course of yellow fever is for the most part fairly uniform 
and consistent, the cases vary in intensity from the mildest to the most 
severe type. Sometimes the patient is struck suddenly with stupor and 
coma j sometimes walking in the streets he may be found to be pulse- 
less, and soon develops jaundice and black vomit, ending in death ; 
whilst in other cases, with natural tongue and natural pulse and general 
calm, he passes abruptly into a condition of black vomit and fatal pros- 
tration. 

According to Guiteras, in young children yellow fever may be a very 
trivial disease, and even when severe is so lacking in characteristic 
symptoms that it is commonly diagnosed as an ephemeral or a thermic 
fever, or as a malarial attack. 

The black vomit consists of gastric mucus with altered blood- cor- 
puscles, epithelial cells, bits of food, various fungi, and black amorphous 
granules, evidently the last results of blood disintegration. Although 
there is without doubt an increased production of urea in the fever stage 
of the disease, yet, according to the researches of Cunisset, the elimina- 
tion of urea is always less than normal, the degree of diminution being in 
direct proportion to the danger of the disease, and affording a very im- 
portant element of prognosis. There is also a lessening in the elimination 
of the chlorides, phosphates, sulphates, and other inorganic salts. The 
amount of albumin in the urine is usually directly proportionate to the 
severity of the attack, but it is possible for a case to go on to death with 
an abundant secretion of non- albuminous urine. Severe albuminuria is 
connected with a diffused nephritis, and is generally accompanied by 
abundant casts. During convalescence parotitis, abscesses, diarrhoea, 
and other local disorders may be very troublesome. 

Diagnosis. — The symptoms of yellow fever in their ordinary develop- 
ment resemble more closely those of certain malarial fevers than of any 
other disease, and in the early days of an epidemic it may be impossible 
to decide from the symptoms alone whether the patient is suffering from 
malarial poisoning or from yellow fever. The diagnosis must be made by 
determining whether the malarial organism is or is not in the blood. The 



230 



GENERAL DISEASES. 



mild cases of yellow fever, such as occur in children, are distinguished 
from thermic or ephemeral fevers by the peculiar icteric hue of the face, 
by the slowness of pulse in proportion to the bodily heat, and sometimes 
by albuminuria. 

Prognosis. — The mortality of yellow fever varies in adults in differ- 
ent epidemics from fifteen to ninety per cent. The disease is about twice 
as fatal in adults as in children. The existence of previous chronic dis- 
ease or of alcoholism enormously increases the danger. The mortality- 
rate is usually much higher in hospital than in civil life, probably on 
account of the exposure and hardships during the earliest hours of the 
disease. Most favorable is a uniform lack of intensity of all the symp- 
toms. If fever, jaundice, or renal disorder is pronounced, the outlook 
is serious. An initial temperature of 103° F. is a bad omen, as is also 
a rapid increase of albumin on the third day. Black vomit usually, 
but not always, presages death. Violent nervous disturbances, such as 
delirium or convulsions, and still more the suppression of urine, are of 
fatal import. 

Prophylaxis. — Absolute exclusion of the germ of yellow fever from 
any locality is an absolute preventive of the fever : hence the importance 
of a most rigid quarantine, the isolation of the sick, and the complete dis- 
infection of clothing, excreta, etc. It is of the utmost importance that 
infected districts be immediately depopulated. The only individual pro- 
phylaxis that is of any value is keeping away from the affected locality. 
There is no reason for believing that the various preventive inoculations 
that have been lauded by Freire of Brazil and Carmona of Mexico are 
effective. 

Treatment. — In yellow fever districts there is still much faith in the 
value of violent sweating, calomel, and similar perturbing agencies in the 
earlier stages of the fever. It seems probable, however, that the best 
results are to be obtained by the expectant treatment, including in this 
absolute rest in bed, especially during the remission, the administration 
of mild saline laxatives, the free internal use of ice- water, the external 
use of cold sponging and baths to reduce temperature, and the meeting 
of the symptoms of adynamia by stimulants. The use of bichloride of 
mercury internally, as suggested by Sternberg, with the idea of destroying 
the supposed specific agent of the disease in the intestines, does not 
appear to have yielded practical results. Guiteras strongly urges the use 
of the tincture of chloride of iron as the best means of checking the 
tendency to black vomit in severe cases. 

When the stomach will bear it, food in the form of broths, milk, eggs, 
etc., should be freely administered. 

Suppression of urine is to be met by the use of hot baths, digitalis, 
pilocarpine, and other usual remedies, the value of which in yellow fever 
cases, however, still remains in doubt. 



INFECTIOUS DISEASES. 



231 



ACTINOMYCOSIS. 

Definition. — A chronic disorder, especially attacking cattle and the 
pig, but capable of transmission to man, produced by the ray -fungus. 

Etiology. — Actinomyces, or ray-fungus, is an organism which was 
discovered by Bollinger in 1877, and is considered by some authorities 
to be a highly organized pleomorphic bacterium allied to cladothrix, 
by others to be a fungus : it produces in man and the lower animals a 
chronic inflammatory affection, whose nature can usually be made out 
by detecting even with the naked eye granules varying in size from a 
small pea to a point, and in color from a translucent grayish to opaque 
gray, yellowish, or brownish, even to black. Examined with the micro- 
scope the granule is found to be a colony or clump of colonies, consist- 
ing of a central interlacing mass of branching and radiating projecting 
threads, with in the centre small, round, cocci-like bodies, and upon the 
periphery the bulbous, club-like terminations of the threads. The cocci- 
form bodies are supposed by some to be spores, and are found both within 
and on the outside of the threads. Usually about the colonies are nu- 
merous bacilli of various species, and also pyogenic cocci. According to 
the researches of J. Israel and M. Wolff, the actinomyces grow best 
anaerobically. Great difficulty has been experienced in producing, either 
with the natural actinomyces or with the result of their culture, disease 
in the lower animals, but Israel and Wolff appear to have succeeded in 
the development of nodules containing typical colonies by introducing 
pure cultures into the peritoneal cavities of rabbits and guinea-pigs. 
Infection of human beings and of cattle has been frequently traced to 
the penetration of wheat, barley, oats, or other vegetable material into 
the tissues. Usually the part affected is the mouth, especially the neigh- 
borhood of the teeth, but the entrance may be through a wound of the 
skin or of any mucous membrane. The disease chiefly occurs in cattle, 
constituting in its ordinary form the so-called big-jatv or lump-jaw. 

Symptomatology. — Actinomycosis usually shows itself as a slightly 
painful, slowly developed growth, which finally forms fistulous orifices 
through which are discharged purulent matters containing the granules 
already described. The usual seat of these growths is the region of the 
lower jaw. The affected bone enlarges, the soft tissues become hardened, 
and finally a large mass is formed which may destroy life by exhaustion, 
by hemorrhage from an ulcerated vessel, or by suffocation. In some cases 
the course of the disease is rapid and destructive, with the formation of 
large abscesses. 

A very rare form of external actinomycosis is that in which the ray- 
fungus finds lodgement under the skin and gives rise to tumors by whose 
suppuration extremely obstinate ulcers are produced. 

The actinomyces may also find lodgement on an internal mucous mem- 
brane and produce disease. In the lungs it may cause a chronic general 



232 



GENERAL DISEASES. 



bronchitis or a peculiar broncho-pneumonia, which is attended, usually 
with fever, cough, abundant, often fetid, expectoration, loss of flesh and 
strength, and the physical signs of bronchitis or of broncho-pneumonia, 
and is followed after a time by various symptoms due to metastasis and 
dissemination of the parasites through distant organs. Actinomycosis 
of the lung may closely resemble chronic tuberculosis in its symptoms, 
but is much less apt to be attended with haemoptysis. Sometimes it 
represents a rapid chronic pneumonia. By involving the pleural cavity 
the ray-fungus may produce a purulent empyema. Lodged in the intes- 
tines it causes indigestion, diarrhoea, local pains, and tenderness, and is 
especially liable to give rise to secondary disease of the liver, which is 
often attended with great enlargement. 

Cases have also been reported in which the fungus has found lodge- 
ment in the brain, producing symptoms resembling those of tumor, or, 
as in a case reported by O. B. Keller, of cerebral abscess. It has been 
affirmed that the lesion in the brain may be primary ; but the fungus 
must in some way have first entered the blood. 

Diagnosis. — The symptoms of an internal actinomycosis vary almost 
indefinitely with the seat of the disease. The only diagnostic mark of 
either the internal or the external disorder is the presence of the actino- 
myces in the discharges. 

Prognosis. — The prognosis in actinomycosis depends upon the seat 
of the disease. If the lodgement is in such place that it cannot be reached 
surgically, death is the almost certain result. 

Te,eatment. — The treatment of actinomycosis is purely surgical. The 
tumor and the surrounding parts should be freely removed until pieces of 
tissue removed show no fungus, and then the wound should be freely 
cauterized. It is affirmed that silver nitrate is especially deadly to the 
fungus, and cures are stated to have been obtained by the free use of the 
solid stick, and also by strong injections of carbolic acid. 

MYCETOMA. 

Madura foot-disease, which is endemic in certain portions of India but 
occurs only in natives, especially in males who work in the fields or go 
about with bare feet, has been shown by Vandyke Carter, confirmed by 
Kanthack, to be simply a form of actinomycosis, the species probably, 
though not certainly, being different from that which is met with in 
Europe and America. The part affected is nearly always the foot, but the 
hand, arm, shoulder, scrotum, or any other portion of the body may be 
attacked. The first change is swelling and redness, followed after a time 
by a superficial or deep papule, which finally discharges pus containing 
white, yellow, black, or reddish, fish-roe-like granules and black, irregu- 
lar masses. As the disease progresses there are severe pain, extraordinary 
swelling, and distention of the foot, giving way of the arch, destruction 
of the bones, and the formation of numerous elevations, which are the 



INFECTIOUS DISEASES. 



233 



orifices of sinuses running into the centre of the foot. The treatment is 
the same as that of other forms of actinomycosis. If taken early, free 
local excision and curetting may suffice. Later, amputation, sufficiently 
high up to get above the penetrating fungus, is essential. The disease 
always ends in death from exhaustion if left to itself. 

RABIES. HYDROPHOBIA. 

Definition.— An acute infectious disease, occurring in various ani- 
mals, and produced in man by the bite of an animal suffering from the 
disease, characterized by a long incubation, paroxysmal convulsions, 
great excitement, fever, and paralysis terminating in death. 

Etiology. — Rabies is especially common in canine animals, though it 
occurs in cats, is said to be very frequent in the American skunk, and 
may be transmitted to the herbivora. The symptoms in the dog are a 
primary rise of temperature, followed by shyness, chilliness, irritable 
suspiciousness, with a tendency to run from home, and a characteristically 
depraved appetite, which causes the animal to eat wood, stones, faeces, 
and even its own tail. There is at the same time altered voice, with a 
peculiar howl, and a little later furious maniacal excitement ; there is 
often at this period or later paralysis of the muscles of the jaw, with 
excessive salivation, causing frothy saliva to drop from the mouth ; the 
whole attack ending in progressive paralysis and death. If the paraly- 
sis develops early, the rabies is spoken of as dumb rabies ; if the excite- 
ment is pronounced, the case is one of f urious rabies. It appears to be 
definitely proved that the bite of the animal may produce rabies as early 
as forty- eight hours before the appearance of the prodromic fever. 

There is no well- authenticated case of the communication of rabies 
from man to man. The nature of the poison is unknown, but according 
to the researches of Pasteur and others it passes up the nerve-trunks 
to the nerve-centres. The virus is in many cases wiped off the teeth of 
the biting dog by the clothing of the bitten person : hence bites upon 
uncovered parts of the body are especially fatal. 

Morbid Anatomy. — The alterations of especial significance in rabies 
are venous injection and thrombosis, cellular infiltration of the adven- 
titia of the veins, first observed by Kolesnikoff, and miliary abscesses, 
originally described by Gowers and soon after confirmed by us. These 
changes have been found in the medulla, in our investigations, near the 
floor of the fourth ventricle. In addition, we have recorded the presence 
of myocardial hemorrhages and oesophageal cedema. 

Symptomatology. — The incubation period of rabies in the dog has 
been experimentally proved to be from six days to eight months. In 
man it is usually considered as between two weeks and three months, 
but it is not very rarely prolonged to a year, and even three years may 
elapse after the bite before the appearance of the symptoms. The disease 
in man may be divided into three stages. The first of these, the pro- 



234 



GENERAL DISEASES. 



droniic, lasts from a few hours to six or eight days, the symptoms being 
malaise, slight fever, hyperesthesia of the special senses, and occasionally 
pains in the scar. The first pronounced symptoms of the stage of excite- 
ment are usually stiffness of the throat and difficulty in swallowing, which 
rapidly increase until all efforts at deglutition produce violent spasm of 
the muscles of the pharnyx, larynx, and upper chest. An intense hyper- 
esthesia, affecting special senses and general sensibility, now develops, 
with an increasing area of muscular involvement by the spasms. The 
paroxysms by and by are produced not only by attempts at swallowing, 
but by the sight of fluids, especially running water, and finally by bright 
lights, loud sounds, or, it may be, even by irritation of the surface of the 
body. Although there is intense thirst, efforts at drinking are accom- 
panied with excessive terror, and if persisted in produce violent tetanic 
spasms, which in rare cases have ended in death by cramp asphyxia. 
Excessive salivation is common. There is usually mild fever. At first the 
intellect is clear, but as the disease progresses delirium develops and may 
become violent. After from a few hours to ten days the paralytic stage 
appears, with increasing loss of power, which commonly commences in 
the muscles of the jaw and spreads to the whole body until it ends in 
paralytic asphyxia. 

Diagnosis. — The diagnosis in rabies depends upon the peculiar respi- 
ratory spasm caused by attempts at swallowing, the intense hyperes- 
thesia, and the concluding paralysis. These symptoms may be closely 
simulated in hysteria, but in all such cases that we have seen the mock- 
ery has revealed itself in an apparent exaggeration but a real lack of 
intensity of the symptoms. 

Prognosis. — The prognosis of developed rabies is fatal. The per- 
centage of cases following the bite of a rabid animal is estimated by 
Horsley at sixteen, by Hunter at five, but by various other authorities 
much higher, even up to eighty. The bites of rabid wolves are four or 
five times as dangerous as those of rabid dogs 5 and, according to popular 
belief, the bite of the rabid skunk is certain death. 

Treatment. — The treatment of developed rabies must be purely 
symptomatic. The question as to the inoculative treatment of Pasteur, 
in which the person who has been bitten is immediately subjected to a 
series of inoculations with the properly prepared spinal cords of rabid 
animals, is a most serious one for the practitioner to decide. Out of seven 
hundred and ten persons who had been bitten on exposed parts of the 
head and inoculated at the Pasteur Institute in Paris, the mortality was 
3.38 per cent., — a result which seems to justify the advising of inocu- 
lation when there is a clear history of bite by a rabid animal upon an 
exposed part. In every case of a suspicious dog-bite it is the duty of 
the practitioner as soon as possible to excise the wounded parts and to 
cauterize thoroughly by hot iron, caustic potash, or other penetrating 
caustic, — a procedure which greatly lessens the danger of infection. 



INFECTIOUS DISEASES. 



235 



ANTHRAX. MALIGNANT PUSTULE. 

Definition. — An infectious disease, produced by the bacillus an- 
thracis, occurring in two forms, — an external, characterized by a peculiar 
pustule having a black centre and surrounded by wide-spread, hard in- 
filtration and secondary pustules ; and an internal, characterized by a 
rapid toxseinia, usually accompanied by hemorrhages from the mucous 
membranes and numerous metastatic carbuncles. 

Etiology. — The anthrax bacillus (Bacillus anthracis), described by 
Pollender in 1849, and especially studied by Davaine, Pasteur, and Koch, 
is a non-motile bacillus, from one to two and a half millimetres broad, 
producing spores, and growing in the open air. Desiccated spores may 
survive for years, and require boiling temperature to kill them with cer- 
tainty. When set free in the soil by superficial burial of carcasses or 
otherwise, they multiply until a local infectious area is produced. Being 
a saprophyte, the anthrax bacillus is capable of passing through all its 
life-phases in the soil outside of the animal organism, so that its entrance 
into animals must be looked upon as accidental. The spores usually pass 
into the lower animals during the grazing months, and are liable also 
to be transported in times of freshet and give origin to new and perhaps 
distant infected districts. 

Almost always man becomes infected through the lower animals : con- 
sequently malignant pustule is chiefly seen among those who work about 
domestic animals, or who are employed in the manufacture of raw prod- 
ucts from animals, the tenacity of life of the spores being such that they 
may remain active in hair, wool, etc., for many years. Thus, malignant 
pustule occurs chiefly among butchers, stable-boys, shepherds, tanners, 
wool-sorters, glue-makers, upholsterers, etc. The infection may be 
through a wound or an abrasion, when external malignant pustule is 
produced ; or by inhalation or swallowing of the spores, with a result- 
ing internal anthrax. In rare cases the infection has been conveyed 
by insects. 

Anthrax is much more frequent in Europe and Asia than in America, 
where it appears to be endemic only in certain districts originally infected 
by importation of the germ. Owing to the robustness of the bacillus and 
its spores, imported hides, hair, wool, and other raw animal products may 
cause the disease in man. 

Symptomatology. — The malignant pustule usually develops upon 
the hands, face, or other exposed portion of the body from a few hours 
to twelve or fourteen days after the infection. It is a small, red, intensely 
itching or burning point, which soon becomes a papule surmounted by a 
reddish or bluish vesicle, which, after bursting and discharging its bloody 
serum, is followed by a dark-brown or blackish crust. The induration 
extends far beyond the immediate neighborhood of the inoculated point, 
and often has radiating from it red streaks or lines, marking progressive 



236 



GENERAL DISEASES. 



lymphatic inflammations. Secondary vesicles surround the central one, 
and gangrene may result. Nausea, vomiting, diarrhoea, fever, delirium, 
excessive sweating, and collapse, appear usually on the second day, and 
death may occur in from five to eight days ; or by abatement of the local 
inflammation and the subsidence of the constitutional symptoms the 
subject may return to health, convalescence being preceded by slough- 
ing off of the vesicle. 

Under the name of malignant anthrax oedema a condition is described 
by Bollinger and others in which the pustule is wanting, and the only 
local symptom is a wide-spread, brawny oedema, which is usually fol- 
lowed by another form of gangrene, great constitutional disturbance, and 
death. 

A malignant oedema has also been recorded in two cases of typhoid 
fever following a hypodermic injection of musk, and caused by a long, 
spore-forming bacillus resembling the anthrax bacillus, but narrower and 
with rounded ends. 

In internal anthrax, or wool- sorters' disease, the invasion is usually 
sudden, with headache, rigor, nausea, vomiting, abdominal pains, and 
diarrhoea. Free hemorrhage may occur from the mouth, nose, and kid- 
neys, and death, preceded by delirium, convulsions, dyspnoea, cyanosis, 
and heart-failure, result. In another form of internal anthrax, in which 
the infection is said to be in the lungs, the symptoms take on the appear- 
ance of a rapidly spreading pneumonia, with great adynamia. The pul- 
monic cases are especially seen among wool-sorters, carpet- and blanket- 
makers, weavers, and other workers in hair- like animal products ; whilst 
the intestinal variety is produced by the eating of diseased meats. 

Diagnosis. — Anthrax is to be distinguished by the fact that whilst 
in carbuncle the local sore is formed by the coalescence of numerous 
points, in anthrax the origin is purely centric. Anthrax oedema is dis- 
tinguished from erysipelatous oedema by its having a grayish or yellowish 
instead of a reddish tint, and by the induration being more distinct and 
less superficial. The diagnosis of internal anthrax is one of great diffi- 
culty, unless there is an outbreak of external carbuncles. Whenever the 
symptoms of a sudden infection appear in a person whose business ex- 
poses him to anthrax infection, the blood should be examined for the 
bacillus, and inoculation of a guinea-pig or a mouse with the blood, or 
with the local products, if there are any, should be practised. The symp- 
toms of anthrax in the guinea-pig or the mouse are rapidly developing 
constitutional symptoms of a general infection, with dyspnoea and con- 
vulsions, whilst the blood swarms with the organism. 

Prognosis. — Under proper treatment, applied early, malignant pus- 
tule is almost invariably recovered from. Under neglect the mortality 
may be seventy-five per cent. The prognosis depends, therefore, on the 
earliness and thoroughness of the treatment. Intestinal and thoracic 
anthrax is in the great majority of cases fatal. 



INFECTIOUS DISEASES. 



237 



Treatment. — The treatment of external malignant pnstule is imme- 
diate, thorough destruction by incision, followed by cauterization with 
the hot iron or by corrosive sublimate or carbolic acid. In the cedenia- 
tous form local injection of the three per cent, solution of carbolic acid 
should be practised, or the parts should be abundantly scarified and 
dressed with carbolic acid solution. In internal anthrax there is no 
known specific treatment : intestinal antiseptics may be tried. In all 
cases of anthrax the general treatment should be supporting, stimulating, 
and symptomatic. 

FOOT-AND-MOUTH DISEASE. 

This is a highly contagious disease of domestic animals, usually occur- 
ring in epidemics, characterized by vesicles, pustules, and ulcers in the 
mouth, at the top and cleft of the hoof, and on the udder. The virus 
is in the discharges from the sores, and also in the general excretions, 
and is transmissible in fomites. It is probably an organism whose 
characters have not yet been determined. In man the virus produces 
disease by direct inoculation, and also through the drinking of milk. 
After an incubation period of from three to five days there is a rigor, 
followed by fever, headache, anorexia, and malaise, and after some days 
vesicles appear on the lips, tongue, and pharynx, and leave ulcerations 
behind them. Vesicles sometimes develop on the hands and feet, espe- 
cially near the nails. As diarrhoea is a common symptom, the mucous 
membrane of the intestines is probably affected. In severe cases there 
may be hemorrhages from the mucous membrane. Eecovery usually 
occurs after about two weeks of illness. In a recent epidemic the mor- 
tality was eight per cent. (Saenger). 

The stomatitis should be treated locally with boric acid solution after 
disinfection with hydrogen dioxide solution, etc. Ulcerative points may 
be touched with solid silver nitrate. The internal treatment should be 
symptomatic, stimulating, and supporting. 

As a measure of prophylaxis, during an epidemic of the disease among 
cattle all milk should be thoroughly boiled before being used. 

GLANDERS. FARCY. 

Definition. — A contagious disease, produced by the bacillus mallei, 
especially attacking horses, but capable of transmission to man. 

Etiology. — Glanders may occur in almost any animal, but chiefly at- 
tacks horses, in which it produces inflammation of the mucous membrane 
of the nose and upper respiratory passages, with cough, fever, purulent 
coryza, and ulceration of the nasal mucous membrane, attended by great 
enlargement of the submaxillary glands and the formation in various 
parts of the body of superficial glandular enlargements, which when hard 
are known as "farcy buds," and when ulcerated as " farcy sores," the 
whole eiuling in death from exhaustion and septicaemia. The virus 
which exists in the nodules and in the discharges from the ulcers and 



238 



GENERAL DISEASES. 



mucous membrane was discovered by Loeffler and Schutz to be a bacillus 
resembling, but shorter and thicker than, the bacillus of tuberculosis. 
The infection of man is usually by inoculation, through an abrasion on 
the hands or elsewhere, with the nasal discharges from the horse, but 
may occur through breathing or swallowing the poison. In a number 
of cases lions and other animals in menageries have been infected by 
eating the meat of diseased horses. 

Glanders is capable of being transmitted from man to man, and in- 
fection of washerwomen has occurred, but the disease is chiefly seen in 
hostlers, coachmen, and others who work about horses. 

Symptomatology. — After an incubation period usually of three or 
four days, but sometimes protracted to fourteen days, acute glanders 
develops, with malaise, headache, anorexia, articular pains, and usually 
but not always fever. At the same time swelling, redness, and inflamma- 
tion of the lymphatics come on at the point of inoculation. Within 
two or three days coryza appears, and rapidly becomes severe and 
purulent, and at or about the same time red spots come out on the face 
and about the joints, or sometimes over the whole surface of the body, 
rapidly developing into hard papules closely resembling those of variola, 
and going on to vesiculation, pustulation, and final ulceration. As the 
disease progresses, deposits occur in the Schneiderian membrane, and 
often also in other portions of the body, forming nodular subcutaneous 
enlargements, " farcy buds." These rapidly suppurate and ulcerate ; the 
coryza becomes more and more severe, with much swelling of the nose \ 
general symptoms of septicemia develop ; not rarely pneumonia comes 
on ; and almost without exception death occurs in from six to twelve 
days. 

The distinction which is made by writers between acute farcy and 
acute glanders has no sufficient foundation, the only difference being 
that in the one case the subcutaneous enlargements are pronounced, in 
the other they are not so strongly developed. 

Chronic glanders in man ordinarily resembles in its course a severe 
coryza, which is distinguished from other forms by a tendency to recur- 
ring ulceration and the formation of contracting and deforming cicatrices. 
In one form of chronic glanders (chronic farcy of writers) there are 
numerous subdermal nodules with resulting abscesses and ulcerations, 
without much inflammation or lymphangitis. This variety is probably 
due to direct inoculation through an abrasion. 

Diagnosis. — The only disease that acute glanders resembles is small- 
pox ; but the occupation of the patient should put the practitioner on his 
guard, and the nasal symptoms make differentiation easy. The recog- 
nition of chronic glanders may be extremely difficult ; in any suspected 
case the bacillus should be looked for, and inoculation of the guinea-pig 
with the discharges or with cultures from the discharges should be prac- 
tised : if the bacillus mallei be present, death of the animal will occur 



INFECTIOUS DISEASES. 



239 



within thirty hours, with in the male enormously swollen suppurating 
testicles. In acute farcy the nose may not be inflamed : here, in any case 
of doubt, inoculation should be practised. 

Prognosis. — Acute glanders always ends in death. Chronic glanders 
may last from three to five months, and is said to have a mortality-rate 
of about fifty per cent. 

Treatment. — There are no known remedies which have any control 
over glanders. If the case be seen early, the points of inoculation should 
be thoroughly destroyed by excision and caustics. G-landular enlarge- 
ments should be opened early. The further treatment should be con- 
ducted on general principles, and should always be supporting and mildly 
stimulating. 

GREASE. 

Grease in horses is a peculiar ulceration between the quarters of the 
heel, with a thick, offensive discharge. By contact with this discharge 
hostlers and others suffer from a superficial pustular eruption. This 
yields readily to treatment, which should consist of thorough washing 
and disinfection and touching the points with weak astringent solution 
(copper sulphate four grains to the ounce, silver nitrate two grains to the 
ounce), or rarely with caustic. 

TUBERCULOSIS. 

Definition. — An infectious disease due to the invasion of the organs 
and tissues by the bacillus tuberculosis. Interstitial and superficial in- 
flammations follow, either circumscribed or diffuse, and the anatomical 
products tend to become cheesy or indurated, the cheesy dead material 
undergoing softening or calcification. The resulting symptoms depend 
partly upon the local disturbances caused by the bacilli, partly upon 
the absorption of the toxic products of their growth, and partly upon 
the modifications in the function of the organ especially diseased. 

Etiology. — The bacillus discovered by Koch in 1882 is the immediate 
cause of tuberculosis in man or in animals, although the infectious nature 
of this disease was ascertained by Klencke in 1843, whose observation was 
forgotten. It was suspected from the anatomical appearances by Buhl in 
1857, and rediscovered by Villemin in 1865. Tuberculous man is the chief 
source of human tuberculosis, yet the disease may be derived from the 
tuberculosis of the domesticated animals. It is rare in dogs and cats, in 
sheep and swine, and prevails among the bovines, but the so-called tuber- 
culosis of fowls is not due to the bacillus of tuberculosis. Of 4093 cattle in 
Massachusetts tested for tuberculosis by means of tuberculin, 1081 reacted 
positively, and were killed, and anatomical evidence of tuberculosis was 
found in all but two. Of 132,294 cattle slaughtered in Copenhagen, 
seventeen and seven-tenths per cent., and of 142,872 killed in Berlin, 
fifteen and one-tenth per cent., were tuberculous. In this connection it is 
interesting to note that the average mortality from tuberculosis in man is 



240 



GENERAL DISEASES. 



in the vicinity of fifteen per cent. The bacilli transferred from man to 
man are generally considered to be largely derived from cases of pulmo- 
nary tnberculosis ; while those transmitted from cattle are probably con- 
veyed by contaminated milk, dairy products, and more rarely by meat. 
The degree of risk of the transfer of tuberculosis from animals to man is 
lessened in the preparation of food. The milk from tuberculous animals, 
even if the udders are not tuberculous, may be dangerous, and should be 
avoided, since Ernst has shown that the milk may contain the bacilli 
although the udders are free from tubercles. Milk from cows with tuber- 
culous udders is dangerous, and must be condemned, and Bang has shown 
also that butter made from the milk of tuberculous cows is infectious. 

The bacilli of tuberculosis enter the body through the skin or by 
means of the respiratory and digestive tracts, and perhaps by the uro- 
genital canal. The skin is invaded when bacilli lodge in a wound, as a 
scratch or tear from the sharp edge of a broken receptacle containing 
tuberculous sputa. The wound occurring in the ritual performance of 
circumcision may become infected with bacilli present in the mouth of 
a tuberculous operator. The surgeon may be infected with bacilli during 
an operation upon tuberculous bones, joints, or glands, and the anatomist 
may become inoculated with the living bacilli in a dead body. The in- 
halation of dried tuberculous sputa, however, is the chief source of tuber- 
culosis of the respiratory tract. The swallowing of tuberculous sputa and 
of food containing virulent bacilli is the principal source of infection by 
means of the alimentary canal. The food most often contaminated is milk 
from a tuberculous cow, especially one whose udders are tuberculous. 
It is also true that the nursing mother may give infected milk from a 
tuberculous breast. The entrance of bacilli by means of the uro-genital 
tract, though rare, is possible in the case of genital tuberculosis of hus- 
band or wife. The above-mentioned sources of invasion of the body are 
usually included under the term acquired tuberculosis. Congenital tu- 
berculosis, on the other hand, sometimes exists, perhaps more often than 
is generally supposed, and is to be explained by the transmission of bacilli 
from the mother to the foetus through the vascular walls in the placenta, 
which organ has been found to contain evidences of tuberculosis. 

The bacillus once lodged in the body and finding favoring opportunities 
for its growth multiplies, and is transferred from the place of entrance 
along mucous surfaces or through lymphatics and blood-vessels, and thus 
gives rise to anatomical changes remote from those which may have been 
produced at the point of entrance. A distinction is hence drawn between 
primary and secondary tuberculosis. The bacilli are present throughout 
the world, since tuberculosis exists everywhere and prevails wherever 
large collections of individuals exist. The disease is less frequent in 
high altitudes, and, as was first announced by H. I. Bowditch and by 
Buchanan, is of increased frequency in low-lying, damp regions. It is 
more frequent in cities and towns than in the country. It abounds 



INFECTIOUS DISEASES. 



241 



in prisons and asylums, and Cornet has frequently found the bacilli in 
the dust of hospital wards. It is, however, maintained that the nurses 
and attendants in hospitals for tuberculous cases are not especially likely 
to become diseased, although Strauss has found the bacilli in the nostrils 
of physicians and nurses caring for tuberculous patients. 

The bacillus of tuberculosis is a non-motile, narrow rod, usually 
somewhat curved, from one-half to two-thirds the diameter of a red 
blood- corpuscle. It is found alone or in groups, and its presence has 
been demonstrated in the sputum, urine, faeces, blood, pus, lymph, and 
tissues of tuberculous patients. It grows slowly at the temperature of 
the body, and when cultivated attains the maximum of its development 
in four weeks. Tuberculin is a toxic product of its cultivation, and is 
of value as a means of testing the presence of tuberculosis in animals. 
Its therapeutic use in man has been productive of harm, and a posi- 
tive reaction may follow its injection into healthy persons. On the 
other hand, tuberculous patients do not always react when it is tried. 
With possible danger and uncertainty of results, its employment in the 
diagnosis of human tuberculosis is to be regarded as generally inexpe- 
dient. Koch endeavored to free tuberculin from its injurious proper- 
ties, and Klebs announces that he has extracted a harmless and benefi- 
cial tuberculocidin from tuberculin. Such an extract is now offered, 
under the name of antiphthisin, as a remedy in the treatment of phthi- 
sis. Especial clinical importance is to be attached to the demonstra- 
tion of the bacilli in sputum and in urine, since the absolute diagnosis 
of the presence of tuberculosis may thus be established. Even in those 
instances in which the bacilli cannot be shown in material of supposed 
tuberculous origin their presence may often be proved by the production 
of tuberculosis in inoculated animals. 

Predisposing causes of tuberculosis are also important, since of all 
exposed to the invasion of the bacilli some or many do not become dis- 
eased. The predisposition may be inherited, since it is universally recog- 
nized that the children of tuberculous parents are in especial danger of 
becoming tuberculous. Such children are commonly called scrofulous or 
strumous. This inherited predisposition is to be explained rather by in- 
creased vulnerability of the tissues and a diminished power of resistance 
than by the actual transmission of the bacilli from the parent to the off- 
spring. A congenital stenosis of the pulmonary artery or malformation 
of the heart may act as a predisposing cause, since these apparently pro- 
mote the progress of pulmonary tuberculosis by unfavorably modifying 
the pulmonary circulation. The young are more prone to become tuber- 
culous than the aged, although a localized pericardial tuberculosis is 
sometimes found in extreme old age. Acquired local predisposing causes 
are also important by enfeebling the power of resistance of the individual. 
Among these are faulty hygienic surroundings, insufficient food, insani- 
tary occupations, especially those favoring the inhalation of irritating 

16 



242 



GENERAL DISEASES. 



dust, acute or chronic inflammation, particularly of the respiratory tract, 
and acute infectious diseases, chiefly those producing disturbances of the 
respiratory organs, as measles, whooping-cough, and influenza. Trau- 
matism favors the growth of the bacilli by diminishing the power of 
resistance of the tissues. Chronic debilitating diseases, as syphilis and 
diabetes, are also of importance in etiology. 

Morbid Anatomy. — The anatomical changes due to the presence 
of the bacillus of tuberculosis are essentially of an inflammatory char- 
acter. An exudation is produced, the quality and quantity of which 
depend upon the number of bacilli present, the structure of the organ, 
and their localized or disseminated presence upon the surface or within 
the tissues of the diseased part. The word tubercle, whence the term 
tuberculosis is derived, is descriptive, and is applied to a little knot, 
node, or granule, the result of the irritation due to the presence of a 
circumscribed collection of the bacilli of tuberculosis within the tissue. 
Such a tubercle was called miliary from its resemblance in size to that 
of a millet-seed, although smaller tubercles, submiliary, may be present, 
and others even smaller can be found with the microscope. The typi- 
cal structure of a tubercle consists of one or more polynucleated giant 
cells in which the bacilli may be found. These are surrounded by large 
endothelioid or epithelioid cells in which also the bacilli may be present, 
and these in turn are surrounded by small mononuclear corpuscles re- 
sembling those prevailing in lymphatic glands. These various corpus- 
cles lie within the meshes of a net -work, the reticulum, which is elabo- 
rated from the fibrous tissue in which the bacilli have become lodged. 
The submiliary and miliary tubercles are composed of agglomerations 
of the minute and microscopical tubercles, which may congregate into 
masses as large even as the fist, and are then designated nodular and 
conglomerate tubercles. 

Variations in the structure and shape of the miliary tubercle may arise. 
The younger the tubercle the more numerous the cells, the less the fibrous 
reticulum. In the pia mater of the brain the tubercles are composed 
almost entirely of small round cells, which are accumulated in the adven- 
titia of the arteries entering the cerebral cortex and in which they appear 
as fusiform swellings. In the lungs the miliary tubercles may represent 
irregular thickenings of the interstitial tissue at the junction of the 
bronchioles with the infundibulum or of the alveolar walls projecting 
into it. Diffused and extensive growth of fibrous tissue may result from 
the presence of the bacillus. The chief characteristics of such growth are 
the abundant production of endothelioid cells, and the presence of the 
bacilli. 

When the bacillus multiplies upon a surface it produces an exuda- 
tion which is largely cellular, but may be fibrinous or hemorrhagic. The 
cells are both those desquamated from the surface, alveolar epithelium, 
for instance, and migrated leukocytes resembling either pus-corpuscles or 



INFECTIOUS DISEASES. 



243 



lymph-corpuscles. An important characteristic of the cellular inflamma- 
tory products due to the invasion of the organs and tissues by the bacillus 
is their tendency to early death. A necrosis occurs, usually beginning at 
the centre of the tubercle or in those cells of a superficial exudation 
farthest removed from their source. It is manifested by a homogeneous 
glistening appearance of the cell, which is readily stained with fuchsine, 
although the nuclei lose the power of becoming differentially stained. 
An absorption of fluid takes place from the dead material, which thus 
becomes transformed into a homogeneous opaque yellow mass in which 
the structural details are lost. To this condition the term caseation, cheesy 
degeneration, or cheesy metamorphosis is applied. The minute tubercle or 
the agglomerated myriads of tubercles may undergo caseation, and the 
inflammatory products on the surface, both cells and fibrin, may become 
similarly metamorphosed. In those organs in which an association of 
superficial and interstitial inflammation is possible the cheesy masses 
often consist of the interstitial tubercle and the superficial inflammatory 
exudation. The group of changes is designated tubercle or tuberculosis, 
the anatomical characteristic the tubercle giving way to the etiological 
unit the bacillus. Tuberculosis thus no longer means a tubercle, but the 
various lesions, superficial or interstitial, due to the invasion of the 
bacillus of tuberculosis. 

The cheesy material tends to become softened or hardened. Soften- 
ing apparently occurs from a soaking of the dead material with fluid, a 
molecular disintegration being the result. The softening occurs more 
rapidly in those parts to which the air is freely accessible, as the lungs, 
and it seems probable that it may be accelerated by the presence of 
other bacteria than those of tuberculosis, and also by the entrance of 
amoeboid corpuscles into the cheesy masses. The softened cheesy material 
may be carried along the passages communicating with the surface of 
the body, and ulcers or cavities result, or be absorbed by means of the 
lymphatics and blood-vessels, or be evacuated through the skin either 
spontaneously or by a surgical operation. In the displacement of softened 
cheesy material from one organ to another a renewal of infection is 
favored, since the cheesy detritus contains the bacilli. 

Cheesy material becomes hardened by the deposition within it of lime 
salts, calcification. The cretaceous mass remains embedded in fibrous 
tissue often throughout the life of the individual, and is usually pro- 
ductive of no further disturbance. 

A fibrous transformation of the tubercle may occur, when many of 
the cells are destroyed, others are transformed into permanent connective- 
tissue cells, and the fibrous reticulum becomes thickened and broadened. 
The fibrous transformation of the tubercle results in the production of a 
sort of scar-tissue, which may retain the shape of the original tubercle or 
appear as irregularly defined collections of dense fibrous tissue, whose ori- 
gin from the bacillus of tuberculosis may be a matter of pure inference. 



244 



GENERAL DISEASES. 



The symptoms depend upon the manner and method of the invasion 
and upon the existence of other disturbing agencies. There are certain 
common features, however, which, although varying in severity and ra- 
pidity of development, are present whatever }3art of the body may be 
invaded. Such manifestations are conspicuously fever and wasting, and 
in former times gave rise to the designations hectic or hectic fever and 
consumption, phthisis or tabes, which were further qualified according to 
the structures affected as pulmonary, renal, intestinal, or mesenteric, and 
according to the rapidity of progress as acute, galloping, or chronic. 

With the recognition of tuberculosis as an infectious disease, stress 
has been laid upon the conspicuous affection of one or more organs or 
sets of organs, since the local symptoms resulting from the disturbance 
of function of these organs are the more especial causes of complaint. 
Although the local manifestations of tuberculosis are usually described 
in connection with the organs diseased, repetition is avoided and the 
importance of the process as a whole is more readily appreciated by the 
consideration of the various manifestations of the presence in the body 
of the bacillus under the one title tuberculosis, with subdivisions classify- 
ing the important clinical characteristics of the disease. 

Varieties. — The most important clinical distinction is that drawn 
between general and local tuberculosis. General tuberculosis affects 
various organs simultaneously or in rapid sequence, and the bacilli are 
distributed chiefly by means of the circulation. Local tuberculosis occurs 
in an organ or an apparatus, and the bacilli are admitted to the region 
concerned largely from the surface exposed to the air, although in part 
through the circulation. A further practical distinction is made between 
acute and chronic tuberculosis. In the former the tubercles are usually 
miliary or submiliary in size, of a gray color, and are generally asso- 
ciated with but little evidence of a superficial inflammatory exudation. 
In chronic tuberculosis extensive agglomerations of tubercles in nodules 
and patches occur. The tubercular masses are opaque yellow from 
cheesy degeneration. Softening, calcification, and fibrous induration are 
of frequent occurrence, and acute and chronic inflammatory changes 
are often associated. General tuberculosis is usually acute, and is often 
called disseminated from the scattered distribution of the tubercles ; 
local tuberculosis is commonly chronic, although it may become compli- 
cated by an acute outbreak of disseminated miliary tubercles. 

GENERAL ACUTE OR DISSEMINATED TUBERCULOSIS. 

This designation is given to the presence of tubercles in various parts 
of the body due to the more or less rapid dissemination of considerable 
numbers of the bacilli. 

Etiology. — Acute general tuberculosis is a secondary process depend- 
ing upon the existence somewhere in the body of a tubercular lesion, 
either apparent or concealed, from which the bacilli are admitted into 



INFECTIOUS DISEASES. 



245 



the circulation. The entrance of the bacilli usually takes place by the 
extension of a local tubercular process in an organ commonly the seat 
of chronic tuberculosis, as the lungs or the lymph-glands, into a blood- 
vessel, especially a vein, or into a lymphatic, notably the thoracic duct. 
This variety is more common in children than in adults, and not infre- 
quently immediately follows an acute affection of the respiratory tract, 
as influenza, measles, or whooping-cough. These diseases apparently 
exercise a favoring influence in promoting the admission of bacilli into 
the blood, perhaps by diminishing the resistance of the tissues to the 
rapid growth of the bacilli towards the nearest vessels. In like manner 
typhoid fever has occasionally been reported as preceding the symptoms 
of a general tuberculosis. 

Morbid Anatomy. — The lesions present are miliary and submiliary 
granules, either projecting from the surface of an organ and easily recog- 
nized or lying within its substance, as in the lungs, spleen, or kidney, and 
readily apparent or to be appreciated only by close scrutiny, even re- 
quiring the use of the microscope for their identification. Few or many 
tubercles are present, and, except in the cerebral pia mater, lungs, and 
kidneys, are usually unaccompanied by other inflammatory exudation. 
The pia mater, lungs, liver, and spleen are the organs in which the 
largest number of tubercles is to be found, although they are also present 
in the kidneys, choroid, heart, thyroid gland, serous membranes, and 
bone-marrow. The predominant localization of the tubercles, as far as 
the symptoms are concerned, is in the pia mater or the lungs. 

Symptomatology. — The general symptoms of acute disseminated tu- 
berculosis closely resemble those of typhoid fever, and are often of rapid 
onset in a person apparently in previous good health, or they may be pre- 
ceded by a gradually increasing sense of malaise. Not infrequently signs 
or symptoms exist of chronic or latent tuberculosis somewhere in the body. 
Chilly sensations often followed by flushing are complained of. The 
patient loses appetite and becomes weak. The symptom which usually 
first calls attention to the nature of the disease is the elevation of tem- 
perature, which frequently has evening exacerbations and morning re- 
missions perhaps with considerable differences, as in the third week of 
typhoid fever. An evening temperature of 103.5° or 104° F. is common. 
Higher degrees are sometimes observed, especially in children, shortly 
before death. The range is often exceedingly irregular, perhaps with in- 
tervals of a few days of relatively normal temperature to be followed by 
almost periodical remissions or intermissions. The morning record may 
be higher than that in the evening, although this is only an occasional 
feature. Very exceptionally there may be little or no elevation of tem- 
perature, and still more rarely it is found subnormal. The elevated 
temperature, accelerated respiration, and rapid and weak pulse in the 
absence of localizing symptoms are directly suggestive of typhoid fever. 
The associated debility, hebetude, sopor or mild delirium, dry tongue, 



246 



GENERAL DISEASES. 



and occasional diarrhoea offer additional suggestive evidence of the same 
process. A rash also somewhat resembling that in typhoid fever is some- 
times observed. 

The area of splenic dulness is increased, although the enlargement 
of the spleen is usually moderate. The bacilli of tuberculosis have been 
found in the blood, but the search for them is so often unsuccessful as to 
be of little or no avail in diagnosis. A moderate leukocytosis may exist. 
The urine is scanty, high-colored, and of high specific gravity, correspond- 
ing to the elevated temperature. A trace of albumin is frequent, and 
the diazo- reaction is often present. The characteristic bacilli have been 
found in the urine, but so inconstantly and under such difficulties that 
they are usually not sought for diagnostic purposes. 

Acute Tubercular Meningitis. — In the further progress of acute 
general tuberculosis the cerebral symptoms may predominate over the 
pulmonary, or the reverse may occur. The cerebral symptoms are often 
so pronounced at the outset that the disease is to be regarded rather as 
one of meningitis than of acute tuberculosis. Although tubercular 
meningitis, as a rule, is the conspicuous localization of a general tubercu- 
losis, the occasional occurrence of tubercular meningitis independent of 
tuberculosis elsewhere in the body may be mentioned. Tubercular men- 
ingitis is especially frequent in children, in whom it is usually secondary 
to tuberculosis of the lymph-glands, tubercular caries of the mastoid, 
or tuberculosis of the brain. The tubercles are most numerous at the 
base of the brain, especially near the optic chiasm and the pons Varolii, 
in the fissures of Sylvius, and upon the upper surface of the cerebellum. 
They appear particularly in the vicinity of injected blood-vessels as 
granules, nodules, and patches, and are to be found as fusiform thicken- 
ings of the adventitia of the minute arteries entering the cerebral cortex. 
They are also to be found, especially in children, in the choroid plexuses 
of the lateral ventricles, whose cavities are dilated with an opaque fluid 
and the ependyma thickened and softened. To this condition the term 
acute hydrocephalus, or dropsy of the brain, was formerly applied. The 
more abundant the distention of the ventricles with fluid, the drier the 
brain, the more flattened the convolutions, and the more obliterated the 
furrows. In the meshes of the pia mater is a more or less extensive in- 
filtration of an opaque yellow fibrino-serous material, especially abundant 
in those parts in which the tubercles are numerous, although it may be 
abundant and but few tubercles be observed. Minute hemorrhages may 
be found in the pia mater and in the brain. Tubercles of the choroid are 
more likely to be present when acute tuberculosis is especially marked in 
the cerebral membranes. Similar alterations may be found in the mem- 
branes of the spinal cord, especially at the upper and anterior portion. 

The symptoms of tubercular meningitis may develop suddenly and 
progress so rapidly, especially among children, that death may quickly 
occur without warning. Usually, however, they are preceded during a 



INFECTIOUS DISEASES. 



247 



week or two by the general symptoms of acute tuberculosis above men- 
tioned. Headache is conspicuous, is sometimes intense, and is usually 
aggravated by light and noise. Nausea, vomiting, unexpected or not, and 
constipation are more or less constant. Delirium and restlessness are 
frequent, and in children grinding of the teeth and convulsions are com- 
mon. Among them a sudden outcry, sometimes a shriek or scream, the 
hydrocephalic cry, is often heard. The head is drawn back, the anterior 
wall of the abdomen becomes concave, and spasmodic contractions of 
various muscles occur. The skin readily shows the taches cerebrales. The 
patient rapidly loses flesh and strength. In the farther progress of the dis- 
ease the irritative symptoms diminish, and those of intracranial pressure, 
the paralytic symptoms, appear. The patient is more quiet, but shows 
increasing dulness of mind. The stupor becomes more profound, and 
Cheyne-Stokes breathing may precede the death of the comatose patient. 
Strabismus and conjugate deviation of the eyes or drooping of the lids 
occur, and the pupils previously contracted become dilated or irreg- 
ular. Localized pareses or paralyses may take place, and Osier notes the 
existence of aphasia and brachial monoplegia. The pulse is frequently 
irregular. Tubercles may be found in the choroid, and the appearances 
of optic neuritis may be observed with the ophthalmoscope. In acute 
general tuberculosis in which the cerebral membranes are especially dis- 
eased death may occur, as already mentioned, with such suddenness as to 
suggest cerebral hemorrhage. More often the symptoms of a meningitis 
persist during a period of two or three weeks, and sometimes, especially 
when the tubercular meningitis is sharply localized, the symptoms are 
mild and are continued over a period of months. 

Acute Tuberculosis of the Lungs. — With a predominant localiza- 
tion of the tubercles in the lungs the condition becomes one of acute 
miliary tuberculosis of the lungs. These organs are distended, injected, 
somewhat increased in weight. The air does not readily escape even 
on pressure, and the tubercles are often to be felt as minute shot-like 
bodies. The pleurae frequently show numerous minute and agglomer- 
ated tubercles. On section of the lungs the miliary and submiliary 
tubercles, either gray and translucent or yellow and opaque, are dissemi- 
nated in greater or less abundance throughout, often projecting above the 
surface. They are not infrequently associated, especially at the apices, 
with large cheesy, sometimes softened nodules, due to an earlier localized 
tubercular process. In the rapidly progressing cases the interstitial mil- 
iary tubercles are unaccompanied by exudation in the alveoli. In the 
protracted cases more or less cellular or fibrino- cellular, perhaps cheesy, 
exudation is present in various quantity within few or many alveoli. 

The onset of acute miliary tuberculosis of the lungs may take place 
so rapidly as to suggest an acute diffuse bronchitis or fibrinous pneu- 
monia. More often with the early prodromal symptoms of general tu- 
berculosis the conspicuous affection of the lung becomes manifested by 



248 



GENERAL DISEASES. 



cough, rapid breathing, and pleuritic pain. The cough is frequently 
persistent, sometimes incessant, the sputum usually scanty, at first con- 
sisting of mucus, but soon becoming muco -purulent, and is sometimes 
streaked with blood. Characteristic bacilli, if present, are to be ac- 
counted for rather by the softening of an antecedent tubercular focus 
than by the acute invasion of the interstitial tissue. The rapid breathing, 
perhaps sixty inspirations per minute, is due in part to the presence 
of a diffused bronchiolitis and to the projection of the tubercles into 
the alveoli and bronchioles, and in part to the tuberculosis of the ner- 
vous system. As a result of the dyspnoea, the patient becomes cyanotic 
out of all proportion to the physical signs of affection of the lungs or 
heart. The pleuritic pain is of frequent occurrence, resulting from the 
presence of tubercles in the pleura, and is accompanied by the sound of 
friction. On physical examination of the chest the resonance is either 
normal or increased, the tympanitic resonance corresponding to the fre- 
quent hyperdistention of the lung found after death. The existence of 
spots of dulness is suggestive of chronic foci of tuberculosis or of acute 
broncho-pneumonic complications. On auscultation fine moist and dry 
rales are distributed throughout the lungs, while towards the end of the 
disease coarse dry and moist rales are numerous. Absence of respiratory 
sounds or tubular breathing and bronchophony may be evident in the 
regions of localized dulness. 

In acute general tuberculosis in which the pulmonary symptoms are 
conspicuous, death may occur in the course of a fortnight after the appear- 
ance of these symptoms, or the progress of the disease is subacute or 
chronic, then extending over a period of weeks or months. The course 
essentially depends upon the sudden or gradual entrance into the blood- 
vessels of few or many bacilli during a longer or shorter period. 
Although this variety is called acute, and generally is so, its progress 
may extend over a period of months as well as of weeks. 

In chronic general tuberculosis as distinguished from acute general 
tuberculosis the symptoms, although similar, are less severe, and periods 
of intermission and exacerbation of various duration occur. Such varia- 
tions are especially indicated by the changes in temperature, periods of 
normal temperature alternating with atypical elevations or periodical 
intermissions, perhaps accompanied with chills, and are for the time being 
suggestive of malarial attacks. Progressive loss of flesh and strength 
and increasing pallor are more conspicuous than severe cerebral or pul- 
monary symptoms. 

Diagnosis. — The diagnosis essentially depends upon the persistence 
of atypical fever without obvious local cause, during the progress of 
which meningitic symptoms occur or dyspnoea and cyanosis arise, the 
latter without sufficiently explanatory physical signs on examination of 
the lungs. It is strengthened by evidence of an antecedent tubercular 
affection in some part of the body, and is definitely established by the 



INFECTIOUS DISEASES. 



249 



discovery of tubercles in the choroid or by the presence of the character- 
istic bacilli in the sputum. 

During the early or typhoid stage indicative of the general infection, 
the range of temperature is the chief means of distinguishing acute 
miliary tuberculosis from typhoid fever. It is atypical and irregular in 
the former, more definitely characteristic in the latter. The presence or 
absence of rose spots, constipation or diarrhoea, meteorism and right iliac 
pain, enlargement of the spleen, and the diazo- reaction, are not signifi- 
cant of either affection. The presence of leukocytosis is in favor rather 
of acute tuberculosis than of typhoid fever. With the predominant 
development of meningitic symptoms the tubercular nature of the men- 
ingitis is to be inferred from the absence of traumatism, of inflammation 
of the middle ear, and of epidemics, the usual causes of meningitis. The 
onset of tubercular meningitis is more gradual, the irritative stage is 
more prolonged, the convulsions are more frequent, and evidence of 
an extensive bronchitis is more often present in meningitis of tubercular 
origin than in the other varieties of this disease. 

If the acute tuberculosis progresses with conspicuous localization in 
the lungs the local physical signs are those of a capillary bronchitis. The 
latter affection, however, is of more sudden onset, with immediate devel- 
opment of the signs of a diffuse bronchitis. The cough is more severe, 
while dyspnoea and cyanosis are less extreme. 

Prognosis. — Acute general tuberculosis is a universally fatal disease. 
The rare cases of reported recovery are based upon the disappearance of 
symptoms. Post-mortem examinations have never shown any anatomical 
evidence by means of which the assumption of recovery from an ante- 
cedent attack of acute general tuberculosis could be maintained. 

LOCAL TUBERCULOSIS. 

This term is applied to indicate the conspicuous presence of tubercles 
or other inflammatory products due to the presence of the bacillus of 
tuberculosis in limited portions of the body, and represents the most 
frequent cause of death in mankind. These products are usually com- 
bined both within the tissues and upon the surfaces. Instances of 
the former are not only the miliary and submiliary tubercles, dissemi- 
nated and in clusters, but also endothelioid or epithelioid cells from 
blood-vessels and lymphatics, perhaps from other tubes also, — bile-ducts, 
for example. The superficial products are the hyperplastic epithelial 
cells from glands, tubules, ducts, and other surfaces lined or covered 
with epithelium, while blood-corpuscles, fibrin, and serum may be found 
as a part of the exudation both within the tissues and upon the sur- 
faces. Local tuberculosis may be conveniently considered under the 
head of tuberculosis of the skin, of the mucous membranes, digestive 
organs, and uro-genital apparatus, of the serous membranes, of the duct- 
less glands, of the nervous and vascular systems, and of the bones and 



250 



GENERAL DISEASES. 



joints, although two or more of these regions may be simultaneously 
affected. 

Tuberculosis of the Skin. — The skin becomes tuberculous by the 
direct inoculation of the bacilli from without, or may arise from the ex- 
tension towards the surface of a subcutaneous tubercular affection, as may 
be seen near the outlet of fistulse communicating with softened cheesy 
lymphatic glands and tuberculous bones and joints. The miliary tuber- 
cles are embedded in greater or less number in a congested fibrous tissue 
containing abundant endothelioid cells. 

According to the circumstances of the infection, the method of the 
extension of the local process, and the nature of the secondary changes, 
various terms are applied. The anatomist's tubercle is represented by 
a sharply defined, reddish, translucent nodule, generally limited to the 
superficial portion of the skin, pertinacious, but not prone to undergo 
extensive secondary changes. In lupus numerous nodules of a reddish- 
brown tint are present. They increase in size, project considerably above 
the surface, and are associated with the abundant formation of epidermis 
or with extensive necrosis. The necrotic tissue becomes softened and 
separated, while a renewal of the infection takes place both laterally and 
below the surface. Extensive scars, with extreme deformity, notably in 
lupus of the face, result from the tendency of the cicatricial tissue to 
contract. The term scrofuloderma is applied when the miliary tubercles 
and diffused tubercular tissue form slightly projecting nodules of a pur- 
plish color, which undergo necrosis and softening and result in the for- 
mation of ulcers with a cheesy base. These ulcers usually occur in the 
vicinity of a deeper-seated tubercular affection, especially of the bones or 
lymph-glands, and are believed to result from the transmission by means 
of the lymphatics of the bacilli from such sources to the skin. Tubercu- 
lous ulcers are also recognized independent of scrofuloderma. They are 
characterized by an irregularly rounded and congested margin and an 
indurated base, in which are opaque yellow specks. Miliary tubercles 
are present both in the base and edges. Further consideration of cuta- 
neous tuberculosis is to be found in works on dermatology and surgery. 

Tuberculosis of the Mucous Membranes. — Tuberculosis of the 
mucous membranes forms the most important group of the tubercular 
affections, and the resulting disturbances are associated with so much 
wasting that they in particular are those which have been usually de- 
scribed under the head of phthisis, consumption, or tabes. The processes 
are essentially the same whether the bacilli are inhaled, swallowed, ad- 
mitted in copulation, or eliminated through the kidneys. The usual 
result is that more or less of the tract in continuous relation with that 
part of the mucous canal first diseased is simultaneously affected : hence 
in tuberculosis of the respiratory mucous membrane the lungs are usually 
diseased, and in tuberculosis of the urinary tract the genitals, especially 
in man, are frequently similarly altered. 



INFECTIOUS DISEASES. 



251 



In tuberculosis of the mucous membranes miliary tubercles result 
from the invasion of the bacillus. They are seated superficially, and. 
tend rapidly to become cheesy. The more abundant and the more liquid 
the outward flow over the mucous membrane, and the more superficial the 
tubercles, the more quickly is the cheesy material removed : hence the 
so-called lenticular ulcers arise, sharply defined and shallow, but tending 
to spread laterally by the confluence of neighboring ulcers. The base of 
the confluent ulcers may be of a grayish-yellow color, from cheesy material 
not washed away. Such ulcers are especially to be found upon the pos- 
terior surface of the epiglottis, in the larynx and larger bronchi, and 
in the ureters and bladder. The smaller the canal the less readily re- 
moved are the cheesy products, which then become inspissated and often 
form an obliterating plug, as in tuberculosis of the smaller bronchi, the 
Fallopian tubes, and the vasa deferentia. In the intestine large and 
indurated ulcers result from the extensive formation of tubercles in the 
base as well as in the edges of the ulcer. The clinical importance of the 
appreciation of tuberculosis of the mucous membranes and its complica- 
tions requires a separate consideration of pulmonary, laryngeal, intestinal, 
and uro-genital tuberculosis. 

Pulmonary Tuberculosis. — This term includes the various disturb- 
ances that result from the invasion of the respiratory tract by the bacillus 
of tuberculosis. Acute miliary tuberculosis of the lungs has already 
been considered as of hsematogenous origin and a part of general miliary 
tuberculosis, although it is possible that a localized acute miliary tuber- 
culosis of the lungs may arise and be disseminated throughout the lungs 
from the inhalation of large numbers of the bacilli in minute subdivision. 
This condition, however, is rare, and its manifestations would not essen- 
tially differ from those described in connection with acute general tuber- 
culosis. 

The more important varieties of pulmonary tuberculosis are those in 
which bacilli are inhaled, the hematogenous form having already been 
considered, and the pleurogenic variety being, in the main, of no practical 
importance. One or more foci of localized tuberculosis are produced, 
from which the lung becomes more and more extensively invaded. 
Although the term pulmonary tuberculosis indicates the seat and cause 
of the disturbances, the lesions are so various that their separate ana- 
tomical diagnosis is often simply problematical. The term phthisis is 
therefore to be preferred as indicative of the especial clinical charac- 
teristic, — namely, the emaciation. Fibroid phthisis has no necessary con- 
nection with tuberculosis. 

PULMONARY PHTHISIS. PULMONARY CONSUMPTION. PUL- 
MONARY TUBERCULOSIS. 

Etiology. — In the etiology of pulmonary phthisis there are certain 
features which have been already mentioned as important in the etiology 



252 



GENERAL DISEASES. 



of tuberculosis. The invasion of the lung by the bacillus is essential, 
and it is chiefly introduced by means of the inhalation of particles of 
dried sputum. Less frequent is the evacuation into the lung of a soft- 
ened tubercular gland or a softened tubercular abscess from caries of 
the spine or ribs. The effects of the invasion vary. Of a number of 
individuals equally exposed the bacillus will find suitable conditions for 
its growth and propagation in some and not in others. Such conditions 
are to be found in an inherited or acquired vulnerability of the tissues. 
Local causes are also important, as is seen in the frequency of pul- 
monary phthisis in persons with a malformed thorax, congenital stenosis 
of the pulmonary artery, previous pleurisy, and following measles and 
whooping-cough, in which contagions the catarrhal affection of the re- 
spiratory tract apparently acts as a localizing cause. 

Morbid Anatomy. — As a result of the presence of the bacilli upon 
the respiratory surface, a series of local changes arise both superficial 
and interstitial. To the former the terms cheesy pneumonia and cheesy 
bronchitis are applied in virtue of the appearance and localization of the 
anatomical products. In cheesy pneumonia the alveoli become filled with 
large cells of an epithelial character, either desquamated alveolar epithe- 
lium or transformed leukocytes. Such cells are prone to undergo rapid 
necrosis, and soon present the caseous appearance. The alveolar Avails and 
the neighboring interstitial tissue become thickened, and a formation of 
large endothelioid cells takes place in them. The smaller branches of 
the pulmonary artery and the alveolar capillaries become obliterated. 
The affected portion of the lung thus contains no air, is solidified, and 
deprived of blood, a condition which has received the term cheesy hepa- 
tization. These alterations are distributed over smaller and larger areas. 
Thus, one may find miliary foci of cheesy pneumonia in which few alveoli 
are affected, or the solidification may exist as a lobular or a lobar pneu- 
monia, or as a broncho-pneumonia. The extent of the primary distri- 
bution of the lesions depends largely upon the number of bacilli inhaled 
and the length of time during which such inhalation has been taking 
place. Bacilli may proceed from such superficial exudation into the in- 
terstitial tissue of the lung and give rise to miliary tubercles as a compli- 
cation of the process. These may abound in the vicinity of the superficial 
changes, but are so incorporated with them that they are often not to be 
identified except when present in relatively normal portions of the lung, 
and especially when seen in the pleura. 

A similar superficial exudatory process occurs in the smaller bronchi 
and results in a cheesy bronchitis, the canal of the bronchus being filled 
with a necrotic exudation, the wall also becoming necrotic after being 
infiltrated with endothelioid cells. An inflammation of the pulmonary 
alveoli surrounding such bronchi may take place, and foci of broncho- 
pneumonia thus arise. These alterations are often earliest found at the 
apices of the lungs, and this localization, according to Orth. depends 



INFECTIOUS DISEASES. 



253 



upon the favorable opportunity for the retention of the bacilli, the les- 
sened resistance of the tissues from the diminished blood-supply in these 
portions of the lung in consequence of their incomplete expansion in 
ordinary respiration, the frequent presence of pleural adhesions, and the 
liability of the bacilli to be forced into the apex by deep and violent 
inspiration during fits of coughing. The bacilli once having produced 
these disturbances in any particular part of the lung, the cheesy masses 
may become encapsulated in cicatricial tissue or impregnated with lime 
salts and indefinitely remain inert. The cretaceous nodules and puckered 
cicatrices so often found, especially at the apices of the lungs, are thus 
explained. 

On the other hand, the chief source of danger from the localized foci 
of cheesy pneumonia is from softening. The softened, cheesy material 
escapes into the larger bronchi, and a cavity results, at first with an irregu- 
lar, opaque yellow wall, the free surface of which continues to become 
softened perhaps more rapidly, as especially suggested by the experiments 
of Prudden, from the presence and growth of other bacteria than the 
bacillus of tuberculosis, while at the same time the surrounding alveoli 
become the seat of the advancing cheesy inflammation. The enlarge- 
ment increases, neighboring cavities become fused, and eventually an 
entire lobe may become cavernous. The larger cavities have a relatively 
smooth wall, upon which an opaque gray pyogenic membrane is adherent 
and from which slight but frequent hemorrhages readily arise. Such cavi- 
ties are crossed by trabecule, which represent the persistence of branches 
of the pulmonary artery whose tissue offers the most resistance to the 
advance of the destructive process. Small aneurisms of these arterial 
branches may be found, and are the source of the extreme, and sometimes 
immediately fatal, hemorrhage which occurs in pulmonary phthisis. 

With an extension of the softening process to the surface of the lung 
the pleura frequently becomes necrotic, is torn during the act of cough- 
ing, and the contents of the cavity enter the pleural cavity, producing a 
pneumothorax rapidly becoming a pyopneumothorax from the associated 
pleurisy. As the softened contents of the cheesy mass, in which bacilli 
in large quantities are present, pass along the larger bronchi, the mucous 
membrane is infected, and miliary tubercles and cheesy bronchitis arise. 
The bacilli are also aspirated, especially during the act of coughing, into 
smaller branches, hitherto uninfected, of the main bronchus through 
which they are passing. JSTew foci of miliary, broncho-, and lobular 
cheesy pneumonia are formed, undergo softening, and are transformed 
into cavities which become confluent, and thus the destruction of the 
lung extends. 

Other changes than those above described are circumscribed cellular 
and fibrino-cellular exudations, which are attributable to the presence 
of other bacteria than the bacillus of tuberculosis. Certain parts of 
the lung are collapsed from a plugging of the respective bronchi, while 



254 



GENERAL DISEASES. 



other portions are in a state of collateral emphysema. Bronchial dilata- 
tion is frequent, and new-formed fibrous tissue abounds. 

The pleuree are usually thickened, sometimes being of almost carti- 
laginous density, and adhesions are formed between the costal and pul- 
monary pleurae, at times so firm that in the removal of the lung the 
costal pleura is torn from the wall of the chest. The thickened pleura 
is often crowded with miliary tubercles, at times agglomerated into 
cheesy masses. The bronchial glands are increased in size, and usually 
contain miliary tubercles and cheesy nodules. The latter tend to be- 
come fused, softened, or calcified, and are often of a dirty gray color 
from the presence of particles of black pigment. 

In many cases of chronic phthisis evidences of tuberculosis are to be 
found elsewhere, especially in the intestine, kidneys, and spleen. Laryn- 
geal and tracheal tuber calosis are frequent complications, while tuber- 
cular endocarditis sometimes is present. Fatty infiltration of the liver 
is common, and amyloid degeneration of the spleen, kidneys, liver, and 
intestine is frequent. 

Symptoms. — In the consideration of the symptoms of pulmonary 
consumption a distinction of practical importance is to be drawn between 
two classes of cases. In the one the disease rapidly progresses, and ter- 
minates fatally in the course of a few weeks or months ; in the other the 
disease slowly advances, and is continued over a period of years. The 
former is the acute, quick, or galloping consumption ; the latter, the usual 
form, is chronic consumption. 

ACUTE PULMONARY PHTHISIS. 

The symptoms of acute consumption may arise in a person iDreviously 
in apparent good health, or may appear in one who has for some time 
suffered from the symptoms and signs of a latent or incipient pulmonary 
tuberculosis, when the unexpected rapid progress of the disease places 
it definitely in the group of acute phthisis. Young persons, particu- 
larly children after measles, whooping-cough, or influenza, are especially 
liable to this variety. The disease may begin suddenly, perhaps after 
exposure to cold or in the sequence of an attack of haemoptysis. Chil- 
liness or a chill is followed by fever, accompanied by cough, a rapid 
pulse, dyspnoea, and pain in the chest. In other cases the symptoms 
suggestive of infection of the respiratory apparatus may be delayed 
for several days or a few weeks, the febrile condition not being accom- 
panied by other than general symptoms. The temperature rapidly rises 
to 103° or 104° F., with morning remissions and evening exacerbations, 
often with daily differences of two or three degrees, which course is 
likely to remain continuous throughout the disease. This continued 
elevation of temperature is often suggestive of typhoid fever, which 
suggestion is favored by the occurrence of hebetude or delirium. The 
patient sweats freely, especially during the daily fall of temperature. 



INFECTIOUS DISEASES. 



255 



There are loss of appetite, rapidly progressive emaciation, and marked 
failure of strength. The respiration becomes accelerated and remains 
quickened, and there may be but little cough or thoracic pain. The cough 
at the outset is simply irritative, with but little expectoration, and may 
be due to an associated laryngitis, in which case there is also hoarseness. 
This laryngitis of the earlier stages of phthisis is the result rather of a 
catarrhal inflammation than of tubercular ulceration. In the latter stages 
of the disease, however, extensive tubercular lesions may be present as a 
result of infection of the larynx by tubercular sputa. Pseudo-membra- 
nous ulcers of the larynx may also occur in phthisis, presumably as the 
result of the presence of other bacteria than the bacillus of tuberculosis. 

The alterations within the lungs are usually found at the apices at the 
onset, but rapidly involve other portions, either continuously or discon- 
tinuously, so that the physical signs at first may be indicative of a 
broncho-pneumonia or a lobular pneumonia, but quickly present the 
characteristics of a lobar pneumonia affecting one or more lobes, perhaps 
the greater part of both lungs. An important characteristic of these 
physical signs is their persistence. The dulness, tubular breathing, and 
increased vocal resonance and vocal fremitus in those regions in which 
the bronchi are not obstructed, with perhaps tympanitic areas from col- 
lateral emphysema or solidification over large bronchi, are also the phys- 
ical characteristics of acute pneumonia. Moist rales are to be heard in 
various parts of the lung. 

The secretion from the lungs may be scanty throughout the course of 
the disease. It is at first mucous, then generally becomes more and more 
purulent, and is usually viscid. It presents the physical characteristics 
of the sputum of a bronchial catarrh. If the patient lives long enough 
for softening of the cheesy products to occur, the sputum becomes more 
abundant, is largely purulent, and contains elastic fibres as well as numer- 
ous bacilli. The latter are to be sought in the sputum raised from the 
lungs, especially in the opaque yellow pus. If but few bacilli are present 
and pus is abundant, Biedert recommends that a drachm of the sputum be 
diluted with three drachms of water and fifteen drops of caustic potash 
and be heated on a sand-bath for two hours. The pus-corpuscles become 
dissolved, and the bacilli, even if few, are readily found in the sediment. 
To detect their presence, thin cover-glasses are to be carefully cleansed in 
water and strong alcohol. A bit of purulent sputum is to be removed by 
a platinum wire freshly heated and spread upon the cover-glass in as 
thin a layer as possible. The smeared glass is then to be carefully dried 
by being held in forceps over the flame of a Bunsen burner. The essen- 
tial characteristic of the bacillus of tuberculosis is that it becomes 
stained by solutions of the aniline dyes to which a mordant has been 
added, and is not decolorized when acted upon by acids and alcohol. The 
stained bacillus sometimes assumes a beaded appearance, attributed to the 
presence of unstained spores or vacuoles. The method of staining recom- 



256 



GENERAL DISEASES. 



mended by Gabbet is the most convenient, since it requires the least time. 
The cover-glass smeared with the sputum, after being dried, is placed for 
a minute or two in a warm solution of one part of fuchsine, five parts 
of carbolic acid, ten parts of alcohol, and one hundred parts of water ; 
it is then to be washed in water and put for a few minutes into a solu- 
tion of methylene-blue two parts, sulphuric acid twenty -five parts, and 
water one hundred parts. It is again to be washed in water, and may be 
examined in this fluid, or may be dipped in alcohol, dried with filter- 
paper, and examined in oil of cedar or any other essential oil. If the 
preparation is to be permanently preserved in Canada balsam it should not 
be examined in oil of cloves, since this agent in time causes the color to 
fade. The bacilli are stained red ; the rest of the specimen is blue. The 
coloring fluids are subject to changes when long preserved, and fresh 
solutions should be occasionally made. 

The progressive involvement of unaffected areas of the lung, or the 
absence of a critical fall of temperature during the second week of the 
disease, may first excite the suspicion of the phthisical nature of the 
process. The presence of the characteristic bacilli usually gives the first 
positive evidence of the tubercular nature of the process. Death may 
occur in a few weeks during this stage of consolidation, or take place in 
the course of two or three months, in which time cavities may arise as the 
result of the rapid softening of the inflammatory product. 

Diagnosis. — The symptoms at the outset being those suggestive of 
typhoid fever or pneumonia, the former is to be excluded by the absence 
of a characteristic range of temperature, the rash, abdominal symptoms, 
a palpable spleen, and perhaps the presence of a leukocytosis. The 
physical examination of the chest shows persistent areas of consolidation, 
to be found only in typhoid fever in the later stages of this disease and 
in the dependent portions of the lung. Acute pulmonary phthisis is to 
be differentiated from acute fibrinous pneumonia by the persistence of 
the signs of consolidation, the considerable daily differences in tempera- 
ture, the lack of a critical fall of temperature, the frequent presence of a 
moderate instead of a considerable leukocytosis, and the eventual appear- 
ance in the sputum of characteristic bacilli. Important suggestive evi- 
dence of the phthisical nature of the disease may be found in the previous 
history or personal characteristics of the patient. 

Prognosis. — Although cases of acute phthisis usually terminate fatally 
in the course of six weeks, a temporary arrest of the process may take 
place and death be delayed for a few months, or chronic phthisis super- 
vene. 

CHRONIC PULMONARY PHTHISIS. 

The symptoms of chronic pulmonary phthisis are usually of gradual 
development, and it is of the greatest practical importance to recognize 
them at the earliest possible moment. A distinction is thus generally 
drawn between incipient and advanced phthisis. 



INFECTIOUS DISEASES. 



257 



In incipient phthisis the patient complains of being rim down, assign- 
ing no cause for the increasing weakness. His friends notice slowly 
increasing emaciation and pallor. The appetite fails, and digestive dis- 
turbances are often complained of. The patient speaks of feeling chilly 
even in a warm room, and admits that slight exertion causes shortness of 
breath. In such persons the use of a thermometer indicates an elevation 
of temperature, a local cause for which first becomes manifest on exami- 
nation of the lungs. In other cases with similar increasing weakness, 
haemoptysis, perhaps after slight exertion, takes place, and is often found 
to be associated with localized physical signs, although months may 
elapse before they appear. In a third series of cases the patient, perhaps 
after some slight exposure to cold or wet or to a draught of air, feels 
chilly and suffers from a frequent cough, at first dry and hacking, then 
moist, which persists in frequency and remains obstinate to treatment. 
This persistence of even an apparently slight attack of bronchial catarrh 
often leads to the recognition of its cause by examination of the sputum, 
even before areas of consolidation are found in the lung. Again, the 
early phthisical symptoms may follow an attack of pleurisy, although in 
such cases the probability of the pleurisy being of tuberculous origin is 
directly suggested. It is, however, possible that a lung prevented from 
expansion by pleuritic effusion may offer suitable opportunities for the 
growth of the bacillus of tuberculosis. 

In brief, the most important suggestive, because the most constant, 
sign is persistent elevation of temperature without obvious cause, often 
associated with chilly sensations and perhaps with frequent sweatings, 
especially at night. More characteristic is the haemoptysis, which is 
the initial suggestive symptom in a large number of cases, although the 
physical examination of the chest may not reveal its source nor that of 
the sputum indicate its cause. 

Sooner or later the physical evidence of the incipient stage of pul- 
monary phthisis is obtained. In the great majority of cases the pul- 
monary signs appear at the apices and near the anterior border of the 
upper lobe, rather more frequently in the right than in the left lung. 
The evidence obtained by percussion is less constant and significant than 
that resulting from auscultation. Dulness should be sought in the fossae 
immediately above and below the clavicle, also in the supraspinous fossae, 
although absence of dulness in either of these regions does not indicate 
that the subjacent apex is free from disease. On auscultation of the same 
regions the signs of chief importance as evidence of incipient phthisis 
are prolonged and harsh expiration and fine moist subcrepitant rales 
at the end of the inspiration, which is often feeble and jerky. Such 
signs are significant merely of a bronchiolitis, while solidification is 
indicated by bronchial or tubular breathing with exaggeration of the 
whispered voice. The cause of this circumscribed bronchiolitis is de- 
monstrated if characteristic bacilli are found in the sputum. At this 

17 



258 



GENERAL DISEASES. 



stage repeated examinations may be necessary, and it is often difficult 
to obtain sufficient sputum for the purpose. 

In advanced phthisis the symptoms of the pulmonary affection are 
more characteristic. Cough and thoracic pain are conspicuous, and the 
respiration becomes constantly quickened. The cough varies in severity 
in the individual cases. At times it may be so slight as to attract no 
attention. Again, it may be so severe and persistent as to awaken the 
patient, produce vomiting, and cause him to fear suffocation. It is 
usually more frequent in the morning, and is sometimes so annoying in 
the night as to prevent sleep. The paroxysms of coughing often occur 
without the raising of sputum, and in persons of sensitive nervous tem- 
perament may be almost incessant until the attention of the patient is 
diverted. 

The sputum which is raised from the lung varies in character ac- 
cording to the stage of the disease and the severity of the process. As 
already stated, in incipient phthisis there may be little or no sputum. 
As the disease advances, that which first appears is rather mucous than 
purulent, perhaps containing minute opaque yellow flocculi, but later 
mucous sputa may alternate with thick purulent sputa, or all sputum 
may be largely purulent. The more abundant the sputum, the more 
likely the presence of cavities due to the softening of caseous masses, the 
size of which may be suggested by the quantity of sputum coughed up. 
Denned masses of purulent sputum but little aerated and sinking in water 
are called nummulated sputa, and are considered to be evidence of the 
presence of cavities. The sputum is often streaked or stained with blood. 
In the former case the congested bronchial mucous membrane is regarded 
as the source of the bleeding ; in the latter, the pyogenic membrane lining 
the wall of cavities is the source. The sputa are sometimes of an ex- 
tremely offensive odor, from the presence of putrescent bacteria in the 
pulmonary cavities. The diagnostic importance of the microscopic ex- 
amination of the sputum for the bacilli has already been mentioned. 
Elastic fibres are often sought for, and frequently with negative results. 
Their presence is indicative of the formation of cavities, although cavities 
may exist and elastic fibres not be found. They are most conveniently 
shown by the examination of a portion of the sputum in caustic potash. 
If they are present in small numbers they are more satisfactorily isolated 
by boiling the sputum in a ten per cent, solution of caustic potash ; after 
some hours the fibres are found at the bottom of the glass. 

Thoracic pain, usually sharply defined, is more frequent as an early 
than as a late symptom of advanced pulmonary phthisis. Its presence 
is indicative of an associated pleurisy, and is the more severe the more 
acute and extensive the latter. The sudden onset of an intense pleuritic 
pain, associated with a rapid and difficult respiration, a rise of tempera- 
ture and pulse, and marked prostration, is suggestive of the rupture of 
the wall of a cavity and the production of a pneumothorax, which usually 



INFECTIOUS DISEASES. 



259 



becomes a pyopneumothorax. The symptoms and signs of this affection 
are more fully considered in connection with the subject of pleurisy. 
(See Pleurisy.) Pleuritic pain is aggravated by coughing, and often 
necessitates rapid and superficial breathing ; but as the pleura becomes 
thickened or the pleural cavity obliterated the pain ceases to be con- 
spicuous. Its situation varies from time to time as previously unaffected 
portions of the pleura become involved, and it is now referred to the apex, 
now to the interscapular or axillary regions. The shortness of breath so 
apparent on inspection of a phthisical patient is not accompanied with 
evidence of suffering. The respiration readily becomes increased on 
slight exertion, but the breathing is difficult only when large quantities 
of secretion obstruct the bronchi and vigorous efforts are required to 
cause their removal. 

When the phthisical alterations of the lung have become advanced, 
haemoptysis is so frequent as often to be a matter of jest among patients in 
health-resorts frequented by consumptives. The spitting of blood may 
occur suddenly and unexpectedly, perhaps waking the patient from 
sound sleep, or it may follow exertion, excitement, or a severe paroxysm 
of coughing. The mere streaking or staining of sputa with blood hardly 
excites comment, and gives rise to no general disturbance. The haemop- 
tysis which is of greater significance is the escape of bright frothy blood, 
apparently flowing into the mouth and rather spit out than coughed up. 
Considerable quantities of blood may thus escape in a short time and 
cause the patient to become decidedly weakened. In general, the loss of 
blood is not an immediate source of danger, and Flint has stated that 
recoveries were more numerous in cases in which haemoptysis occurred 
than in those in which it was absent, though recurring and consider- 
able hemorrhages produced a corresponding degree of anaemia with its 
various symptoms. Immediately fatal hemorrhage from the rupture of 
aneurisms into cavities may take place, death being in part occasioned 
by the immediate loss of blood, but being also in part dependent upon 
asphyxia from the filling up of the lung by the blood. 

Physical Examination. — On inspection, the chest is usually either 
long and narrow or flattened in the antero -posterior diameter. This 
thoracic formation is regarded rather as a cause than as the result of 
the disease. The greater the degree of emaciation the more prominent 
are the ribs, clavicles, and scapulae. The ribs usually project, and the 
intercostal spaces are conspicuous. The fossae above and below the 
clavicle and the supraspinous fossae are abnormally deep. One or both 
supraclavicular spaces may be shrunken and incapable of distention, 
from a thickened, adherent, and retracted pleura and from solidifica- 
tion of the pulmonary apex. Defective expansion of the chest may be 
seen on the side of the affected lung. The skin, especially over the ster- 
num, frequently shows a yellowish-brown discoloration, from pityriasis 
versicolor. Clubbing of the fingers and incurvation of the nails are 



260 



GENERAL DISEASES. 



frequent in chronic cases, and similar changes may take place, though 
to a less degree, in the toes. 

Palpation, as well as inspection, reveals a defective expansion, espe- 
cially of the apices. By palpation during phonation may be recognized 
the modification of the tactile fremitus, which is increased over solidified 
portions of the lung and diminished in the presence of pleural effusion 
or thickening. Normally, the tactile fremitus is somewhat more marked 
at the right than at the left apex. 

Percussion gives evidence of solidification with or without a thickened 
pleura, and of the presence of cavities when of considerable size and of 
superficial seat. In solidification there is dulness tending towards flatness 
and accompanied by a sense of increased resistance ; if the dulness is 
slight, it is best recognized at the end of prolonged inspiration. If there 
is a superficial cavity, percussion elicits a high-pitched tympanitic tone, 
the pitch being higher, as shown by Wintrich, when the mouth is open, 
and, according to Gerhardt, also changing with a change of the patient's 
position from the dorsal to the upright or the reverse. The resonance on 
percussion may be but little altered in case of minute disseminated areas 
of solidification or in miliary tuberculosis, and may be tympanitic over 
the apices from the presence of cavities. A dull tympanitic note may be 
present in the absence of cavities when extensive solidification of the 
lung overlies the large bronchi near the root of the lung. Absolute flat- 
ness is indicative of a combination of extensive solidification of the lung 
and a thickened pleura with or without the presence of fluid. If fluid is 
absent, the chest is retracted ; if it is present in sufficient quantity, the 
ribs are separated and there is no motion of the intercostal spaces. 

Beginning consolidation of the lower lobes is usually first apparent at 
their upper portions, which lie in the interscapular regions on a level 
with the fifth dorsal vertebra. 

On auscultation the evidence of obstruction to the entrance of air into 
the bronchioles is furnished by a diminished and often jerky inspiration. 
More constant and important is prolongation of the expiratory sound. 
The respiration assumes a tubular character when the lung-tissue sur- 
rounding the open bronchi is consolidated. Rales are to be heard even 
before dulness or tubular breathing is apparent. In the earliest stages 
the fine crackling, crepitant, or subcrepitant rale is to be heard at the 
end of inspiration, especially on coughing or when a long breath is drawn. 
As the disease advances and the sputum resulting from the associated 
bronchitis is raised, coarse and fine, moist and dry rales are numerous, 
either localized or widely distributed, according to the extent of the 
process. When the cheesy material softens and cavities are formed, 
coarse bubbling or gurgling rales are to be heard, and, at times, sounds 
suggesting a metallic tinkling. Increased vocal resonance gives impor- 
tant evidence of consolidation, and in the early stages of phthisis is 
best determined by listening at the apices for the whispered voice. The 



INFECTIOUS DISEASES. 



261 



vocal resonance transmitted through a cavity often assumes a bleating 
sound, to which the term segophony or pectoriloquy is applied. Over 
the unaffected portions of the lung, especially when extensive solidifi- 
cation exists, the normal broncho-vesicular murmur becomes harsh, rude, 
or puerile. The presence of an associated pleurisy is indicated' in its 
early stage by the sound of friction or rub, while a chronic thickening 
of the pleura or an accumulated exudation produces a muffling or an ob- 
literation of the respiratory and vocal sounds. 

The existence of a cavity is to be determined by the following group 
of sharply defined physical signs. Percussion produces a dull tympa- 
nitic note, amphoric in character in large cavities with thin walls, and 
perhaps presenting a cracked-pot sound best to be heard when the mouth 
is open, especially if the orifice of the stethoscope is placed in front of 
the mouth. On auscultation the respiration is tubular, cavernous, or 
amphoric, according to the size of the cavity. The rales are bubbling or 
gurgling, and may have a metallic sound. The vocal resonance is hollow, 
amphoric, or segophonic. 

A hasmic systolic murmur is frequent both at the apex and in the 
region of the valves of the pulmonary artery, and the signs of acute 
endocarditis sometimes occur. The heart-sounds are freely transmitted 
in the region of large cavities, and a subclavian murmur is often heard, 
attributable to pressure upon or traction of the subclavian artery. The 
cardio-respiratory murmur or systolic souffle ceasing when the breath is 
held may be heard over the larger bronchi. 

Course and Duration. — During the progress of chronic phthisis 
the persistent cough and fever and the loss of flesh and strength are 
the conspicuous symptoms. The fever pursues an extremely irregular 
course, and frequent observations during the twenty- four hours may be 
necessary to determine its character. There are times when the exacer- 
bations are so periodical as to suggest malaria, and again these may 
alternate with days of normal temperature. Indeed, in many cases of 
chronic phthisis the temperature may remain normal or subnormal for 
long periods of time. The intermittent or remittent types of fever are 
called hectic, and are usually associated with flushing of the cheeks and 
considerable sweating. The latter is more frequent at night, although it 
may occur by day or night, usually while the patient is asleep. The night- 
sweats in particular not infrequently form a most annoying symptom. 

The various functions of the body are disturbed. The condition of the 
mind is notably one of activity, even of exhilaration, and, despite grave 
symptoms, the patient remains hopeful. The general or local symptoms 
of intracranial tuberculosis already mentioned arise when meningeal or 
cerebral tuberculosis occurs as a complication, and the numbness or pain 
characteristic of a peripheral neuritis sometimes is present. There is no 
other disturbance of the circulation than is made evident by the rapid 
pulse associated with the fever and by the diminished force attributable 



262 



GENERAL DISEASES. 



to the accompanying atrophy of the heart. According to Henry, the 
anaemia of phthisis does not progress as this disease becomes more severe. 
Acute endocarditis is rare, but thrombosis of the pelvic venous plexus 
and of the veins of one or both legs occasionally occurs in the latter 
stages of the disease. The venous thrombosis is a cause of oedema in one 
or both legs, also of tenderness along the course of the femoral vein, and 
may prove a cause of sudden death by the production of embolism of the 
pulmonary artery. 

There are loss of appetite, nausea and vomiting, distress from food, 
and diarrhoea. The vomiting is often induced by coughing, and the diar- 
rhoea may become persistent and severe. In the latter case tubercular 
ulcers or amyloid degeneration of the intestinal mucous membrane is to 
be suspected. Tubercular ulcers of the intestine may infect the peri- 
toneum and cause a general or a circumscribed peritonitis, resulting in 
fistulous communications between neighboring portions of intestine or 
between the intestines and a hollow organ or the abdominal wall. Anal 
fistula is a frequent complication of both the early and the late stages 
of phthisis, and may be of a tubercular nature, as is suggested by its 
occasional resistance to therapeutic measures. 

The urine not infrequently shows a trace of albumin, especially during 
the febrile exacerbations, and in the latter stages of the disease may con- 
tain abundant albumin, one-half per cent, or more, from a complicating 
amyloid degeneration of the kidney. The quantity is then increased, the 
color pale, the specific gravity in the vicinity of 1010, and hyaline and 
fatty casts are present. If tuberculosis of the uro-genital tract exists as 
a complication, the urine may contain pus, blood, and the characteristic 
bacilli. 

The menstrual function is eventually suppressed in advanced phthisis. 
During the earlier stages, although the catamenia are scanty, pale, and 
watery, pregnancy may occur, in which case the progress of the disease 
is frequently arrested and temporary improvement in the condition of the 
patient takes place. After the birth of the child, however, the disease 
is likely to advance with renewed activity. 

The duration of chronic phthisis is very uncertain. The frequency 
of the evidence of healed tuberculosis in persons who have recovered 
from the disease is familiar to all pathologists, and the indefinite arrest 
of incipient tuberculosis is a fact of daily observation. The gravity of 
chronic tuberculosis is known as well from personal experience as from 
the mortality statistics. The disease advances, comes to a stand-still, is 
retrograde, and again advances, its course extending over many months 
or a few or an indefinite number of years. Death usually results from 
increasing debility and eventual pulmonary oedema, or it may occur from 
a complicating acute disease, as pneumonia or typhoid fever. In certain 
cases anaemia and debility are accelerated by amyloid degeneration, and 
the patient dies with conspicuous symptoms of amyloid nephritis. In 



INFECTIOUS DISEASES. 



263 



other cases delirium, sopor, and coma due to tubercular meningitis may 
be the signs of impending death, while in still other instances the patient 
may die of cerebral anaemia or suffocation from sudden and severe pul- 
monary hemorrhage. 

Diagnosis. — The early stage of chronic phthisis is alone difficult of 
diagnosis, which ultimately depends upon the discovery of the character- 
istic bacilli in the sputum. The physical signs of a persistent bronchio- 
litis, or of consolidation at one or both apices or elsewhere in the lung, 
especially when associated with an elevation of temperature, are sig- 
nificant of phthisis. They are of especial importance in those cases in 
which the bacilli are not discovered, owing either to the absence of a char- 
acteristic sputum or to the presence of the bacilli in very minute quanti- 
ties. The persistent presence of the bacilli is essential to the diagnosis of 
a tubercular phthisis, since they may at times be in the sputum without 
having obtained a permanent lodgement in the lung. Even with the 
signs of cavity and chronic cough the presence of the bacilli is essential 
to the diagnosis of phthisis, since chronic bronchitis and bronchiectasis 
of non-tubercular origin may give rise to such signs. The discovery of 
elastic fibres is less essential to the diagnosis of tuberculosis than to the 
recognition of the destruction of lung-tissue. 

Prognosis. — The prognosis of phthisis becomes the more grave the 
farther advanced the disease. In the incipient stage it is usually rela- 
tively favorable provided the patient can sufficiently control his surround- 
ings. Even with the lack of such control recovery is not infrequent, as 
is shown both by clinical observation and by anatomical investigation. 
Unfavorable prognostic signs are persistent elevation of temperature, pro- 
gressive loss of weight, repugnance to food, and chronic diarrhoea. The 
occurrence of such complications as tubercular meningitis, laryngitis, 
pneumothorax, and amyloid disease of the abdominal viscera is usually 
indicative of a speedy termination. 

LARYNGEAL PHTHISIS. 

This term is indicative of chronic tubercular affections of the larynx. 
Such are usually secondary in character to pulmonary tuberculosis, and 
are attributable to the passage through the larynx of sputa containing 
the bacilli of tuberculosis. As a rule, superficial miliary tubercles arise, 
which rapidly become necrotic, and lenticular ulcers result, tending to 
spread laterally. The older and larger ulcers have an opaque gray or 
grayish-yellow base, from necrotic tubercles, and are present throughout 
the larynx, but are most abundant upon the epiglottis and in the vicinity 
of the arytenoid cartilages and the false vocal cords. Extensive destruc- 
tion of the epiglottis may take place, and an arytenoid perichondritis is 
of frequent occurrence, resulting in sequestration of the cartilages, which 
may be coughed up. The mucous membrane is injected and swollen, and 
hemorrhages may be present. 



264 



GENERAL DISEASES. 



Another variety of tuberculosis of the larynx is to be seen in lupus 
of this organ, which is usually the result of the extension inward of 
a cutaneous lupus. This affection of the larynx is characterized by 
papillary outgrowths from the epiglottis and the vicinity of the vocal 
cords. Such outgrowths become thickened and nodular, and undergo 
necrosis, and ulcers result which may heal with the formation of exten- 
sive cicatrices. 

Laryngeal phthisis may develop in the early stages of pulmonary 
phthisis before extensive lesions are apparent, in which case its primary 
nature is suggested. More frequently it develops late in the disease. 
Hoarseness may occur, the degree of which may vary from time to time, 
and even complete loss of voice arise. Frequent rasping cough, laryn- 
geal pain, and difficulty in swallowing are significant symptoms. The 
difficulty in swallowing may be such that excessive irritation of the 
larynx arises and spasm of the glottis follows. Eegurgitation, perhaps 
vomiting, occurs, and suffocation is threatened. The secretion from the 
larynx is of slight or moderate quantity, is purulent, and often contains 
specks of blood, while characteristic bacilli are present. Laryngeal 
phthisis is rarely recovered from except in the earliest stages, although 
lupus of the larynx may heal. The duration of the symptoms is largely 
dependent upon that of the pulmonary affection, and, like the latter, 
when not especially severe, may extend over years. The diagnosis is 
based upon the recognition of the anatomical changes by means of the 
microscope, and confirmed by the discovery of typical bacilli in the 
secretion removed from the larynx. 

FIBROID PHTHISIS. 

This term denotes chronic alterations of the lung resulting in the for- 
mation of abundant fibrous tissue with a corresponding atrophy of the 
parenchyma. The condition is essentially one of chronic fibrous pneu- 
monia, and has received the designation of cirrhosis of the lung. The 
limited formation of fibrous tissue is of frequent occurrence in the course 
of chronic phthisis, due to the presence of the bacilli of tuberculosis, 
but in that affection the wasting of the individual and that of the lung 
predominate over the formation of fibrous tissue. In fibroid phthisis, 
so called, the fibrous changes in the lung predominate over the wasting 
of the individual. It is possible that the bacillus of tuberculosis may 
produce extensive diffused thickening of the fibrous tissue of the lung 
in the absence of its more characteristic results, but when the bacilli 
are found in fibroid phthisis they are usually associated with cheesy 
conditions and are to be regarded as a complication. Fibroid phthisis 
is to be considered as the result of an acute pneumonia, a chronic bron- 
chitis, or broncho -pneumonia from the inhalation of dust, or it may 
follow a chronic pleurisy. The symptoms are somewhat similar to those 
occurring in phthisis of tubercular origin. Cough, abundant expectora- 



INFECTIOUS DISEASES. 



265 



tion, and some shortness of breath on exertion, with, in general, absence 
of fever and fairly good health, are characteristic of the condition. The 
further consideration of this subject will be found in connection with 
that of chronic fibrous pneumonia. 

TUBERCULOSIS OF THE ALIMENTARY CANAL. 

Tuberculosis may affect the alimentary canal from the mouth to the 
anus, although it is rare in all parts except the small and the large intes- 
tine. It occurs both as a primary and as a secondary affection. The 
former is to be seen in the indurated tubercular ulcers of the lips and 
tongue, which are often attributed to syphilis or cancer. Secondary 
tuberculosis is the rule, and the infection of parts above the pharynx 
usually results from the extension of lupus, cutaneous tuberculosis, into 
the mouth and pharynx, with the production of nodules, ulcers, and 
scars. Tuberculosis limited to the pharynx is usually secondary to that 
of the larynx, and the tonsils, base of the tongue, soft palate, and pos- 
terior wall of the pharynx may be affected, the disease even extend- 
ing into the oesophagus. This portion of the alimentary canal may 
also become tuberculous from the evacuation into it of a tuberculous 
abscess of the vertebrse or of a softened tubercular bronchial gland. As 
elsewhere in the mucous membranes, the initial miliary tubercles become 
necrotic, are disintegrated, and the debris is carried away, leaving super- 
ficial ulcers tending to become confluent, and extending in depth by the 
invasion of the subjacent tissue by the bacilli. Sharply defined ulcers 
result, having an indurated base, speckled with gray and yellow, and 
showing but little inclination to hemorrhage. Tubercular ulcers may 
also be found in the stomach, although their presence in this viscus is 
rare. In most cases they are the result of the escape into the organ of 
the softened contents of neighboring cheesy glands. A tuberculous fistula 
may be established between the colon and the stomach, and tuberculosis 
of the stomach may result from the extension inward of a tuberculosis 
of its serous covering. The resulting ulcers are usually small and not 
associated with symptoms, although Orth states that they have caused 
death by producing hemorrhage and perforation. 

INTESTINAL TUBERCULOSIS. 

Next to the lungs the intestines are the most frequent seat of tubercu- 
losis, being affected in about one-half the cases of this disease. 

Etiology. — Intestinal tuberculosis usually results from swallowing 
bacilli, although it sometimes occurs from the extension of a tubercular 
peritonitis to the mucous membrane or follows the evacuation through 
the intestinal wall of a softened tuberculous gland. According to the 
source of the bacilli a distinction is drawn between a primary and a 
secondary variety of intestinal tuberculosis. Primary tuberculosis is 
found more especially among infants, and is considered to be due chiefly 



266 



GENERAL DISEASES. 



to the use of infected milk. Secondary tuberculosis is more frequent in 
adults than in children, and is chiefly due to tuberculous sputa, although 
milk, dairy products, and meat from tubercular animals sometimes fur- 
nish the bacilli. 

Morbid Anatomy. — In primary intestinal tuberculosis the lesions of 
the intestine consist of ulcers similar to those to be mentioned as due to 
secondary tuberculosis. In primary tuberculosis, however, the infection 
of the mesenteric glands from the intestinal mucous membrane may be 
so extreme that the alterations of these glands predominate over the 
changes in the mucous membrane. To this condition as found in children 
the term tabes mesenterica or tabes meseraica was formerly applied. The 
enlarged cheesy glands were considered to be manifestations of scrofula, 
but the tubercular nature of the alterations in the mesenteric glands is 
not only suggested by the microscopical appearances, but has also re- 
peatedly been proved by the discovery of the bacilli and by the pro- 
duction of tuberculosis by inoculation of the cheesy material. Such 
tubercular glands are usually, though not necessarily, associated with 
tubercular ulcers of the intestine. The relation is thus analogous to 
that observed when cheesy bronchial glands are found without evidences 
of tuberculosis of the lungs. 

Ulcers are the essential characteristic lesions of a tuberculosis of the 
intestine. They are usually largest and most numerous at the lower end 
of the ileum, but may be found disseminated throughout both the large 
and the small intestine, or may be limited to various portions of either, 
especially to the caecum, the appendix, and the flexures of the colon or 
rectum. The primary lesion results from the presence of the bacilli of 
tuberculosis within the lymph-follicles, whether these are solitary or 
agglomerated in Peyer's patches. The tubercular tissue is produced, 
becomes necrotic and softened, and the overlying mucous membrane 
gives way, thus permitting the softened cheesy material to be evacuated 
into the intestine. A tubercular ulcer results, crater-like, with swollen 
injected edges and a gray or grayish-yellow base. The bacilli extend into 
the immediate vicinity, producing new tubercles, which also become 
caseous : hence the spread of the ulcer in width and depth, especially 
the former. In Peyer's patches the progress of the ulcer follows rather 
the width than the length of the patch, in accordance with the course of 
the lymph- vessels, and when the edge of the patch is reached the con- 
tinuous mucous membrane becomes infected, and thus annular or girdling 
ulcers result. The peritoneum overlying the ulcer often contains trans- 
lucent or opaque miliary tubercles, and, in the more chronic varieties, 
beaded and varicose opaque yellow lines, tuberculous lymphatics, are 
seen through the peritoneum to extend from the ulcer to the mesentery, 
and even along the latter to the nearest lymphatic glands, which become 
enlarged and cheesy from tubercular infection. 

The usual tendency of the ulcer is towards extensive destruction of 



INFECTIOUS DISEASES. 



267 



the mucous membrane, at times resulting in perforation, and it is the 
most frequent cause of tubercular peritonitis. Partial or complete heal- 
ing of the ulcer occurs, although rarely, and then for the most part in 
the case of single or few ulcers. A pigmented scar remains, which, if 
the result of a girdling ulcer, may produce an extreme degree of nar- 
rowing of the intestine. 

Symptoms. — Chronic diarrhoea is the characteristic symptom of pri- 
mary intestinal tuberculosis, and often alternates with temporary periods 
of relatively normal evacuations, and even with occasional constipation. 
The dejections contain abundant slimy material, which at times is blood- 
stained, and they are usually rather pultaceous than watery, either white, 
yellow, green, or brown, according to their frequency, the medicines 
used, and the nature of the food. The odor is often extremely offensive. 
The more numerous the dejections the more likely are the stools to be 
fatty and to contain undigested food. The movements of the bowels are 
often excited by food or drink, and are usually preceded by colicky 
pains, which are relieved by the evacuation. The appetite is frequently 
excessive, and the desire for solid food greater than that for liquid nour- 
ishment. The child becomes pale and emaciated, but the abdomen swells 
and is tense from the presence of gas in the intestine. Except over the 
abdomen, the skin is flaccid, its surface dry and rough, and the wrinkled 
face suggests that of old age. The eyes become sunken, and in infants 
the fontanelle also is depressed. The fever presents the general char- 
acteristics of the fever of tuberculosis, periods of intermission and re- 
mission being frequent, while intervals of subnormal temperature occur. 
During the febrile exacerbations profuse sweating takes place, especially 
from the head and back. Eather a sense of discomfort than suffering 
from pain is the rule. The distended abdomen is usually not tender, 
and as the tension is relieved by the escape of gas, the enlarged mesen- 
teric glands, the especial characteristic of primary tubercular enteritis, 
are made apparent. They are to be recognized as resistant, somewhat 
movable tumors of a lobulated character, perhaps as large as pigeons' 
eggs, most frequently in the right iliac fossa and in the vicinity of the 
navel. The lymphatic glands in the groins, axill£e, and neck may be 
enlarged. Circumscribed abdominal tumors may also result from the 
extension of the tuberculosis to the peritoneum, with the formation of 
adhesions and exudations in the region of the appendix, between coils 
of intestine, and in the omentum. The course and results of primary 
intestinal tuberculosis are essentially those of the secondary variety. 

Secondary tuberculosis of the intestine is frequently combined with 
pulmonary tuberculosis in both young and old. It may give rise to no 
symptoms, or may be characterized by diarrhoea, constant or occasional, 
in either case not readily yielding to treatment, while exceptionally actual 
constipation may be associated with extensive tuberculosis. The stools 
are usually painless, and often occur by night as well as by day. They 



268 



GENERAL DISEASES. 



are, as a rule, light- colored, and may contain abundant slime, especially 
when the large intestine is the seat of the ulcers, and blood is sometimes 
present in small quantity. The bacilli of tuberculosis may be found in 
the intestinal contents by the method employed for their recognition 
in the sputa. ~No diagnostic importance, however, is to be attached to 
their presence if the lungs are simultaneously affected, because of the 
frequency with which sputa are swallowed. Abdominal pain is usu- 
ally slight, although occasional attacks of colic occur. The pain when 
present is often referred to definite parts of the abdomen, especially to 
the lower half, and tenesmus occurs when tubercular ulcers are present 
in the lower part of the rectum. The abdomen is retracted, and may 
be the seat of tender points indicative of extension of the ulcers towards 
the peritoneal surface of the intestine. If the tuberculosis is localized 
in the appendix or at the lower part of the rectum, the symptoms may 
be those of an appendicitis, a proctitis, or an ischio-rectal abscess, the 
tubercular nature of which is to be suspected only from the persistence 
of the symptoms and their failure to disappear under appropriate treat- 
ment. If intestinal obstruction follows the healing of the tubercular 
ulcer of the small intestine, its origin may be obscure, since solitary 
ulcers usually progress without symptoms. 

Diagnosis. — The diagnosis of primary intestinal tuberculosis is based 
upon the persistence of the diarrhoea, the progressive anaemia and ema- 
ciation, and the discovery of the enlarged mesenteric glands. The latter 
feature, the most essential in diagnosis, may not be made out until 
towards the end of life. In like manner the diagnosis of the tubercular 
enteritis may first appear probable with the development of signs of 
tuberculosis elsewhere, especially of a tubercular peritonitis or menin- 
gitis. The diagnosis of secondary tubercular enteritis is based upon the 
occurrence of chronic diarrhoea in pulmonary tuberculosis. Amyloid 
degeneration of the intestine also occurs in the course of pulmonary 
phthisis and produces a diarrhoea. In such cases, however, evidence 
of amyloid degeneration is likely to be found in the spleen, liver, and 
kidneys. It is to be remembered that both amyloid degeneration and 
tuberculosis may be present in the intestine. The results of the extension 
of tubercular ulcers of the intestine to the peritoneum will be considered 
in connection with tubercular peritonitis. 

TUBERCULOSIS OF THE LIVER. 

In all cases of general tuberculosis, in most cases of abdominal tu- 
berculosis, and frequently in pulmonary tuberculosis, the liver contains 
tubercles, the bacilli probably being introduced by means of the blood- 
vessels and the lymphatics. Disseminated miliary tubercles are oftenest 
present, and may occur in enormous numbers, although many are invisi- 
ble without the microscope. They are to be seen with the unaided eye 
beneath the peritoneal covering and on section of the liver as minute, 



INFECTIOUS DISEASES. 



269 



opaque white spots seated near the periphery of the lobules. They are 
easily distinguished when the liver, as is frequently the case, contains 
abundant blood, and, on the contrary, are recognized with difficulty when 
there is fatty infiltration of this organ. The tubercles are sometimes 
fibrous, and may then be associated with a cirrhotic condition of the 
liver. 

Nodular tubercles also occur, either alone or with miliary tubercles, 
and are intimately connected with the bile- ducts, as is evident from the 
bile-stained softened centre of these nodules. Such tubercles are often 
larger than cherry-stones, and are cheesy at the periphery and softened 
at the centre. Their appearance suggests that the wall of the bile- ducts 
is first infected, and that the formation of tubercles takes place around 
them, producing results analogous to those occurring in tubercular peri- 
bronchitis. 

Finally, a localized tuberculosis of the liver sometimes, though rarely, 
is present and forms a tumor as large as an egg. This is of a yellow 
color throughout, and miliary tubercles are to be found at the periphery. 
There are no symptoms characteristic of hepatic tuberculosis. 

Tuberculosis of the Pancreas. — Tuberculosis of the pancreas is 
rare, whether in the form of disseminated or of localized tuberculosis. 
Miliary tubercles may be found in the vicinity of tubercular lymph- 
glands lying near the pancreas. Like hepatic tuberculosis, the pancreatic 
affection has no symptoms of clinical importance. 

UROGENITAL TUBERCULOSIS. 

The uro-genital tract is often the seat of tuberculosis, and the in- 
fection is generally considered to take place by the admission of bacilli 
through the blood-vessels. This is suggested by the frequency of miliary 
tuberculosis and tubercular nodules in the kidney without any tubercu- 
losis of the ureters or bladder, and also by the occasional occurrence of 
extensive tuberculosis of the apices of the Malpighian pyramids without 
any affection of the mucous membrane of the pelvis. The possibility of 
an ascending affection from below, either by the admission of the bacilli 
through the urethra or from a prostatic tuberculosis, has previously been 
mentioned. In the male a concurrent affection of both the urinary and 
the genital tract is common, owing to their unification at the neck of the 
bladder, while in the female such concurrence is infrequent, the urinary 
tract being diseased more often than the genital organs. Hence tubercu- 
losis of the kidneys, prostate, seminal vesicles, vasa deferentia, epididy- 
mis, and perhaps of the testicle, is frequently associated. In the female, 
however, the tuberculosis is commonly limited to the urinary or to the 
genital tract. In the latter case the infection of the genital mucous 
membrane may be hematogenous, or the bacilli may enter the tubes from 
the peritoneal cavity and infect both them and the uterus from the 
mucous surface. The cervix and vagina are rarely tuberculous except in 



270 



GENERAL DISEASES. 



the far advanced cases of tuberculosis of the body of the uterus and the 
Fallopian tubes. Local tuberculosis of each part of the uro-genital ap- 
paratus is of practical importance and demands separate consideration. 

Renal Tuberculosis. — Miliary tuberculosis of the kidneys has long 
been recognized, but the tuberculous nature of the so-called scrofulous 
kidney, or renal phthisis, has become a matter of general acceptance only 
since the discovery of the bacillus of tuberculosis as the cause of this 
affection. 

Disseminated miliary tuberculosis of the kidney is part of a general 
miliary tuberculosis, and is manifested by the presence of few or many 
minute, gray, more or less opaque tubercles surrounded by an injected 
border. They are more abundant in the cortex, and readily observed on 
removal of the capsule. On section linear clusters of the tubercles are 
often to be seen continued towards the pyramids. Such disseminated 
miliary tuberculosis of the kidneys is usually bilateral and associated 
with a like affection of the bladder, prostate, or testicles, and there 
are no symptoms especially calling attention to this localization in the 
kidneys. 

Chronic renal tuberculosis, renal phthisis, or scrofulous kidney, occurs 
oftenest during the middle third of life, although the extremes of life are 
not spared. It is frequently unilateral, and is manifested by the extension 
of cheesy masses from the apices of the Malpighian pyramids upward 
into the cortex of the kidney. At the periphery of these cheesy portions 
miliary and agglomerated gray and cheesy tubercles are to be seen. On 
microscopic examination the tubules are filled with necrotic epithelium, 
and large numbers of the bacilli of tuberculosis are often found. The 
interstitial tissue is also infiltrated with cells and is necrotic. The un- 
affected portions of the kidney become invaded by the bacilli, either 
along the tubules or by the entrance of the bacilli into the lymphatics 
or blood-vessels. 

Softening of the parts first involved — namely, the apices of the pyra- 
mids — takes place as the disease advances into the substance of the 
kidney. A series of cavities thus arise continuous with the pelvis of 
the kidney, the intervening septa of normal tissue becoming more and 
more narrow as the invasion of the kidney progresses, till eventually 
the kidney may become a mere fibrous bag filled with liquid and curds, 
or both wall and contents may be so infiltrated with lime salts as to form 
a calcareous shell enclosing a mortar-like material. More often the kid- 
ney becomes enlarged and forms a tumor which is usually symmetrical, 
although the tubercular process may localize itself in a definite portion 
of the organ. 

As the process in the kidney advances, the mucous membrane of the 
pelvis of the kidney, ureter, and bladder is invaded, miliary tubercles 
form in the superficial portion of the mucous membrane, and, becoming 
necrotic, their detritus is washed away in the urine. The infection 



INFECTIOUS DISEASES. 



271 



extends in depth especially by means of the lymphatics, so that the 
entire wall eventually becomes a cheesy ulcer in which islets of rela- 
tively unaffected mucous membrane may exist. The contrast between 
the cheesy tubercular ulcer and the relatively normal mucous membrane 
is most conspicuous in the ureter and bladder. Both the pelvis of the 
kidney and the ureter frequently undergo extreme degrees of dilatation, 
and extension of the process to the paranephric tissue may occur and 
a perinephric abscess result. Amyloid degeneration is not infrequent 
in the course of chronic renal tuberculosis. 

The symptoms which call attention to the disease of the kidney are 
of gradual onset, and are usually preceded by symptoms referable to the 
bladder, especially by frequent micturition. There is discomfort or pain, 
and eventually a resistant swelling, apparently a symmetrical enlarge- 
ment, in the region of one or both kidneys. The urine is usually acid, 
albuminous, and contains pus-corpuscles, increasing in number as the 
disease progresses. Blood, epithelium, and granular material are also 
present. The bacilli of tuberculosis are to be sought in the sediment by 
the method followed in the examination of the sputum. Repeated ex- 
aminations may be necessary, and in cases where the disease is not far 
advanced and the sediment is but slight, the centrifugal apparatus is of 
value in concentrating the bacilli. It is to be remembered that in the 
preputial smegma a bacillus has been found which resembles the bacillus 
of tuberculosis in appearance and in reaction to stains. The former, 
however, becomes immediately decolorized in alcohol, while the bacillus 
of tuberculosis retains its stain when exposed for several minutes. The 
general symptoms of chronic tuberculosis — namely, irregular fever, night- 
sweats, progressive emaciation and debility — are present. 

Chronic renal tuberculosis affecting both kidneys is generally fatal 
during the course of from one to three years after its recognition. The 
possibility of recovery from unilateral tuberculosis has long been recog- 
nized, through the discovery, after death from other causes, of the remains 
of an old tuberculous process, which may be sometimes so extensive as to 
have led to the complete destruction of the kidney. Of late years the 
extirpation of a tuberculous kidney has repeatedly been followed by the 
recovery of the patient. 

Tuberculosis of the Bladder. — Tuberculosis of the bladder is usu- 
ally due to infection from the kidney, although it may proceed from 
tuberculous disease of the prostate, a hematogenous miliary tuberculosis 
of the bladder as part of a general tuberculosis being very rare. The 
anatomical appearances are essentially similar to those of the lesions oc- 
curring in the larger bronchi or the larynx. Superficial lenticular ulcers, 
at first discrete, coalesce and form ulcers of various size with a crenated 
outline and injected margin. These ulcers are most abundant at the neck 
of the bladder, in the vicinity of the orifices of the ureters, but may also 
be found at the fundus. As the disease progresses and infection of the 



272 



GENERAL DISEASES. 



wall of the bladder extends in depth, destruction of the mucous membrane 
occurs, the muscular coat is exposed, the subperitoneal tissue may be 
invaded, and peritonitis follow, or paracystic abscesses and fistulas result. 

The symptoms are those of a persistent vesical catarrh gradually 
increasing in severity. The neck of the bladder is especially sensitive : 
hence there is frequency of micturition associated with vesical tenesmus 
and painful flow of urine, the pain often radiating from the perineal 
region. Slight or considerable hematuria, often unexpected, is fre- 
quently the first sign suggestive of serious vesical disease. The urine 
is acid, with a trace of albumin, and contains but little sediment, which 
is composed of leukocytes, vesical epithelium, and blood- corpuscles. If 
the tuberculosis is limited to the bladder the bacilli are found with dif- 
ficulty, and failure to discover them does not affect the diagnosis. Event- 
ually the symptoms of a chronic febrile cachexia and those of tubercu- 
losis elsewhere, especially in the uro-genital tract, become apparent, and 
the urine is likely to contain an abundant sediment, in which are the 
curds and blood-stained clots perhaps containing the bacilli. In the early 
diagnosis of tubercular cystitis suspicion should be aroused by the oc- 
currence of chronic cystitis without obvious cause, resistant to treatment, 
while the urine is acid. 

Tuberculosis of the Prostate and the Seminal Vesicles. — Acute 
miliary tuberculosis of the prostate is extremely rare. Chronic cheesy 
tuberculosis, on the contrary, is common, and is often associated with 
renal and vesical tuberculosis and with tuberculosis of the testis. This 
affection of the prostate is more frequently the result than the cause of 
tuberculosis of the urinary apparatus, while it may be either a cause or 
a result of an accompanying tuberculosis of the testicle. The bacilli are 
supposed to enter the gland- ducts, infect the wall, and produce desqua- 
mation and necrosis of cells and a tubercular infiltration of tissues. As 
a result the prostate becomes more or less enlarged on one or both sides, 
nodular or not, hard or soft, according to the size and number, necrosis, 
calcification, or softening of the tubercular masses within the prostate. 
The softened caseous masses are discharged into the bladder and leave 
cavities with cheesy walls. Perforation of the wall of the prostate, re- 
sulting in a tubercular infiltration of the neighboring fibrous tissue, takes 
place. Similar changes are found in the seminal vesicles, and in extreme 
cases the prostate and the vesicles may be transformed into a convoluted 
capsule filled with cheesy material in which lime salts are abundant. 

The symptoms of prostatic tuberculosis resemble those of vesical 
tuberculosis. There is long- continued pain of gradual onset, referred to 
the perineum, and to the neck of the bladder or the rectum, and perhaps 
radiating towards the testis. The chief symptoms are a frequent scanty, 
opaque white or yellow urethral discharge, occasionally scanty hsema- 
turia, especially at the beginning of micturition, and a urine resembling 
that found in tuberculous cystitis. 



INFECTIOUS DISEASES. 



273 



The diagnosis is largely based upon the extreme sensitiveness of 
the prostatic portion of the urethra to the passage of a sound, and the 
eventual nodular enlargement with considerable variations in density of 
the prostate and seminal vesicles. The diagnosis of the tubercular nature 
of the palpable prostatic changes is strengthened by evidence of tubercu- 
losis elsewhere in the uro -genital tract, and may be established by the 
discovery of the bacilli in the urine. Eectal examination of the prostate 
may often first indicate the existence of renal or vesical tuberculosis, 
or it may corroborate a diagnosis of tuberculosis of the testis. 

Tuberculosis of the Testis.— Miliary tubercles may be found in the 
testicle as part of a general miliary tuberculosis, and they may also be 
found as the result of the extension of a tubercular process from the 
epididymis. Chronic tuberculosis of the testis usually proceeds from the 
epididymis, the latter becoming infected by the passage of bacilli from 
the bladder or prostate along the vas deferens. Tuberculosis may re- 
main for a long time limited to the epididymis and the vas deferens, 
the wall of which is thickened, the surface infiltrated with necrotic 
tubercular tissue, and the canal filled with cheesy plugs. The epididymis 
may thus be transformed into a dense mass nearly as large as the testis 
which it encircles. In time the tubercular infection is likely to progress 
from the epididymis into the testis, which then becomes enlarged from 
the presence of tubercles and the formation of fibrous tissue. With the 
occurrence of softening the body of the testis may represent a series of 
cavities divided by fibrous septa and filled with cheesy material. The 
sac of the tunica vaginalis may contain more or less fluid or may be 
obliterated by adhesions. The softened cheesy material may escape 
through the adherent skin, in which are formed one or more chronic 
fistulse with tuberculous walls. Such is the so-called scrofulous testicle, 
which often diminishes in size and increases in density with the per- 
sistence of the discharge. 

There may be but little pain associated with tuberculosis of the tes- 
ticle except during the stages of softening and beginning ulceration of 
the skin, although discomfort results from the weight of the consider- 
ably enlarged gland. The importance of palpation of the testicle in 
possible uro-genital tuberculosis is obvious, and this gland should be 
examined although the patient may be unaware of any abnormality 
connected with it. 

Tuberculosis of the Sexual Organs of the Female. — The primary 
nature of tuberculosis of the genital tract of the female is suggested by 
the occasional isolated affection of the Fallopian tubes, while its extension 
as a secondary process from the peritoneal cavity is evidenced by the 
predominant alteration of the tubes when the uterus is involved, the 
rarity with which the ovaries are simultaneously tuberculous, and the 
usual freedom from disease of the cervix uteri and vagina. Observations 
of acute miliary tuberculosis of the mucous membrane of the uterus and 

18 



ft 



274 



GENERAL DISEASES. 



Fallopian tubes and of the ovary are rare. Chronic tuberculosis of these 
organs, with the exception of the ovaries, is by no means infrequent, and 
the alterations of the genital tract may predominate over the evidence of 
tuberculosis in other parts of the body. Usually they are accompanied 
by tuberculosis elsewhere, especially in the lungs. 

Tuberculosis of the uterus is indicated by the presence of miliary 
tubercles in the mucous membrane, which coalesce and degenerate while 
the infection extends deeper into the wall. The uterus becomes enlarged, 
its cavity is dilated, and an extensive cheesy ulcer is formed as in chronic 
tuberculosis of the kidney or the lungs. The tubercular affection of the 
uterus usually begins in the region of the tubes and ceases at the internal 
os, although the cervical portion of the uterus may become affected when 
the uterine tuberculosis is long continued or in the rare event of the 
occurrence of an extension of the tuberculosis from the vagina upward. 
Tubal tuberculosis is usually double, and the tubes become elongated, 
dilated, and tortuous. Tubercular infiltration of the wall exists, and the 
canal is filled with cheesy material. Tubal tumors thus arise, the tuber- 
cular nature of which is usually unsuspected, since the symptoms are 
those common to chronic salpingitis. 

Primary tuberculosis of the tubes may be productive of the hectic 
fever of chronic tuberculosis extending over a period of years, as in the 
case reported by Channing. and the symptoms of perforation into the 
rectum may eventually occur. 

The ovaries may be the seat of miliary tubercles or may form tumors 
of considerable size with softened cheesy contents, as in tuberculosis of 
the testicle. If ovarian tuberculosis exists, it is usually accompanied by 
tubal and uterine tuberculosis, although the tubes and the uterus are 
often tuberculous when the ovaries are normal. The symptoms of tu- 
berculosis of the genital tract of the female are those of chronic endo- 
metritis, salpingitis, or ovaritis, and the tubercular nature of the disease 
is usually first made known by the examination of the specimen removed 
at a surgical operation or at a post-mortem examination. 

TUBERCULOSIS OF THE MAMMARY GLAND. 

Of late years attention has been directed to the occurrence of tuber- 
culosis of the mammary gland, which in the main has been found in 
females, especially during the period of child-bearing. The bacilli in 
certain cases are brought from a remote region probably by the blood- 
vessels, while in others they are directly introduced from neighboring 
tuberculous ribs or skin. Few or several cheesy nodules are present in 
the gland, and when softened are evacuated through the skin with the 
production of fistulse. The skin of the breast also may become tubercu- 
lous, and the corresponding axillary glands are usually affected. The 
disease, when deep-seated, is to be suspected from the constant presence 
of circumscribed nodules of hard or soft consistency, which tend towards 



INFECTIOUS DISEASES. 



275 



ulceration and the formation of fistulse, and from the association of 
permanent enlargement of the axillary glands. An important diag- 
nostic feature is the evidence of tuberculosis elsewhere, and the diag- 
nosis is to be definitely established by the recognition of typical bacilli 
in the pus or scrapings from the wall of the sinus, or by the inocula- 
bility of the discharge from the fistulse. 

TUBERCULOSIS OF THE SEROUS MEMBRANES. 

The pericardium, pleurae, and peritoneum are frequently infected by 
the bacillus of tuberculosis. Although tuberculosis of the serous mem- 
branes may be part of a general infection in which the bacilli are trans- 
ferred to the diseased membrane by means of the blood- current, usually 
each serous membrane becomes infected by the extension of tubercular 
processes from a neighboring part into the overlying membrane. Thus, 
pericardial tuberculosis commonly arises by the passage of bacilli from a 
tuberculous bronchial lymph-gland or from tubercular lungs, sternum, or 
spine. Pleural tuberculosis results from the passage of bacilli from a 
tuberculous lung or a tuberculous process in the spine, ribs, or sternum. 
Peritoneal tuberculosis most frequently is due to the passage of the ba- 
cilli from a tuberculous ulcer of the intestine, from the lungs through 
the diaphragm, from tuberculous mesenteric glands, or from tubercular 
Fallopian tubes. When tuberculosis affects one of these serous mem- 
branes the bacilli are often readily transferred to the others : hence tuber- 
culosis of the several serous membranes often concurs. In acute miliary 
tuberculosis of these membranes gray translucent tubercles may be pres- 
ent, with no other inflammatory products or evidences of inflammation 
than a certain quantity of serous fluid in the cavity affected. Usually, 
however, the tubercles are associated with the products of exudative 
inflammation, — namely, serum, fibrin, or cells. The anatomical condition 
is therefore one of tubercular pericarditis, pleuritis, or peritonitis of a 
serous, fibrinous, or cellular character. The affection may be both acute 
and chronic, the latter being farther characterized by the formation of 
fibrous tissue. All tuberculosis of serous membranes is essentially in- 
dicative of an inflammatory cause : hence the distinction between tu- 
berculosis and tubercular inflammation of the membrane concerned is 
simply one of degree. 

Tubercular Pericarditis. — Tuberculosis of the pericardium is usually 
acute, and is characterized by the presence of tubercles, fibrin, and more 
or less liquid exudation, the latter often being hemorrhagic. The tuber- 
cles may be readily overlooked, but are made evident when the fibrinous 
adhesions are removed from the thickened pericardium, in which they 
appear as minute, opaque gray specks often so closely approximated as 
to form plates, which are seen to best advantage on transverse section of 
the pericardium. Earely the pericardial exudation is purulent. 

Especial interest is connected with the occurrence of tubercular peri- 



276 



GENERAL DISEASES. 



carditis in very old people, in whom it may be the immediate cause 
of death, being the sole conspicuous lesion found. In such cases the 
presumption is strong that the bacilli of tuberculosis have remained 
for many years inert in some part of the body, oftenest in the bron- 
chial lymph-glands, and, suddenly entering the pericardium, cause its 
inflammation. It is also possible that they enter the circulation at a 
remote point and are engrafted upon a pericarditis due to other causes. 
In chronic tubercular pericarditis the tubercles are present as well in the 
fibrous adhesions as in the thickened pericardium. The opposed sur- 
faces are firmly adherent to a greater or less extent, and cheesy masses 
composed of necrotic tubercles and inspissated exudation are to be found 
embedded in the adhesions. The symptoms and signs of acute tubercular 
pericarditis are largely those of acute pericarditis of non-tubercular 
origin, while those of chronic tubercular pericarditis are usually masked 
by the symptoms of tuberculosis elsewhere. 

Tuberculosis of the Pleurae. — In pleural tuberculosis the conditions 
are essentially the same as in pericardial tuberculosis. The exudation is 
usually abundantly serous, and is frequently hemorrhagic. As in peri- 
carditis, so in pleurisy the tubercles may first be made evident after re- 
moval of the fibrinous false membrane, when they are seen mottling the 
surface or forming thick layers. Although tubercular pleurisy is usually 
secondary to tuberculosis in the immediate vicinity, it is probable that 
many cases of acute exudative pleurisy are due to a tubercular infec- 
tion of the pleurae. The bacilli may be in such limited quantity as not 
to be found on microscopical examination of the exudation, but the 
inoculation of guinea-pigs with the latter has frequently resulted in 
the production of tuberculosis. Eichhorst, for instance, has recently 
reported positive results in fifteen out of twenty-three inoculations of 
serum from patients attacked with acute idiopathic pleurisy. Acute 
tubercular pleurisy may be suppurative both in children and in adults, 
and in pyopneumothorax of phthisical origin the combination of sup- 
purative and tubercular pleurisy is often seen. Chronic tubercular pleu- 
risy is the combination in the pleurae and adhesions of recent and 
cheesy tubercles and of inflammatory products inspissated, softened, or 
calcified. This variety is the frequent result of extensive chronic pul- 
monary tuberculosis, and also represents a terminal stage of acute tuber- 
cular pleurisy and tubercular empyema. Since the local manifestations 
of acute or chronic pleurisy are essentially the same whatever the cause 
of the inflammation, their clinical features will be considered in con- 
nection with the subject of pleurisy. 

TUBERCULOSIS OF THE PERITONEUM. 

The presence of tubercles in the peritoneum is associated with the 
variety of inflammatory products found in the other serous cavities. 
On account of the size of the cavity, the extent of surface, and the 



INFECTIOUS DISEASES. 



277 



number and variety of the organs covered by the peritoneum, the ana- 
tomical results form a more complex grouping. The relative significance 
of the primary source of peritoneal tuberculosis may be seen from the 
statement by Pribram that of one hundred and sixty-five cases of peri- 
toneal tuberculosis examined after death, eighty-seven were attributed 
to intestinal tuberculosis, sixty-five to pulmonary and glandular, eight 
to tubal and uterine, and five to osseous tuberculosis. In one hun- 
dred and seven autopsies of tuberculosis in which the peritoneum was 
affected, the lungs were simultaneously diseased in ninety -nine cases, 
the pleurse in sixty, the intestines in eighty, the retroperitoneal glands 
in forty-four, the spleen in forty, the kidneys in thirty-eight, the liver 
and suprarenal capsules each in sixty-six. According to Osier, tu- 
bercular peritonitis is most common between the ages of twenty and 
forty years, and is rare in old age. Although pulmonary tuberculosis 
affects either sex with equal frequency, the statement of Konig, that of 
one hundred and thirty- one cases of laparotomy in which tubercular 
peritonitis was found ninety-two per cent, were females, is significant 
that the distinction was not critically drawn between tubercular and 
chronic granular peritonitis. On the other hand, it is not to be denied 
that the granules which have been seen in chronic granular peritonitis 
may have been fibrous tubercles whose specific characteristics had 
become lost. The often reported concurrence of fibrous hepatitis and 
tubercular peritonitis is of interest as suggesting that a non -inflammatory 
pathological process involving the peritoneum may favor the invasion of 
the latter by the bacilli of tuberculosis from elsewhere in the body and 
result in the production of their characteristic disturbances. 

Mohbid Anatomy. — The lesions of tubercular peritonitis, like those 
of the non-tubercular variety, are diffused or circumscribed, and are 
represented by the association of tubercles and exudation. The appear- 
ances vary in accordance with the predominance of the one or the other, 
and are influenced by the extent and duration of the process. The diag- 
nosis to be beyond question demands the appreciation of more than the 
gross appearances of the tubercle. These are sufficiently indicated by the 
meaning of tubercle, — namely, little knob or node. Similar nodules, even 
miliary in size, occur without other evidence of a tubercular nature in 
chronic peritonitis. In doubtful cases, therefore, the diagnosis of the 
nature of the tubercle demands a microscopical examination with refer- 
ence to structure and to the presence of characteristic bacilli. In the 
absence of the latter, inoculation of the suspected material is necessary 
before the absolute diagnosis of tuberculosis can be made. 

A circumscribed growth of tubercles is often unexpectedly found 
when the abdomen is opened either by the surgeon or at an autopsy. 
It may be limited to the peritoneum overlying a tuberculous ulcer of 
the intestine, or may be found in the vicinity of a tuberculous Fallo- 
pian tube or in the peritoneal covering of the diaphragm in tubercular 



278 



GENERAL DISEASES. 



pleurisy or pericarditis. Such localized tubercular peritonitis is of little 
clinical significance unless active or sufficiently extensive to result in 
the production of tumors, the characteristics of which are soon to be 
stated. 

If tubercular peritonitis is part of a general acute miliary tuber- 
culosis, the peritoneum may be smooth, shining, transparent, at the most 
injected, but is studded with gray, glistening, translucent granules smaller 
than a pin's head, and projecting slightly above the surface. There may 
be but a few ounces of clear yellow fluid in the peritoneal cavity. 

When tubercular peritonitis becomes the principal tubercular lesion 
in the body, the alterations of the peritoneum are far more extreme. 
The peritoneum is thickened and opaque, sometimes pigmented from 
extravasated blood. The tubercles are opaque, grayish- white, or yel- 
low, and tend to become clustered into patches and nodules. Serum, 
fibrin, and sometimes pus are found in the exudation, and red blood- 
corpuscles may also be present. As a rule, the more abundant the serum 
the less the fibrin. The former may lie free in the peritoneal cavity 
or be enclosed within fibrinous false membranes. Fibrin is present as 
a layer covering the peritoneum and often concealing the tubercles 
lying within the latter, or it forms bands or cords uniting different por- 
tions of the peritoneum. Fibrous adhesions and fibrous thickenings of 
the peritoneum, both of which may contain tubercles, eventually result. 
Owing to the contraction of this fibrous tissue and the abundant forma- 
tion of tubercles, tumor-like masses may be produced. The omentum 
may be shrivelled into a dense sausage-shaped mass, or adherent coils of 
small intestine may form a globular mass closely attached to the spine 
by the contracted mesentery. Tumors composed of serum, fibrin, and 
tubercles may be formed between adherent peritoneal surfaces, especially 
in the pelvis and in the iliac fossae. The adjacent intestine may become 
perforated from without, perhaps in several places, and more or less of 
the softened and disintegrated exudation be discharged into the intestine. 
The abdominal wall may also be perforated, and the contents of the in- 
testine escape through such openings. If the tumor is in the right iliac 
fossa, the vermiform appendix may lie at the bottom of such a sinus in 
the abdominal wall, and its tip, if non- adherent, be exposed by slight 
muscular exertion, as in coughing. If there are extensive adhesions and 
little serous exudation, the peritoneal cavity may become largely obliter- 
ated and the abdominal wall retracted. 

Symptoms. — The onset of a tubercular peritonitis is often so gradual, 
the symptoms so latent, and the course so prolonged, that the disease 
may be unsuspected until enlargement of the abdomen is apparent. 
Even then the tubercular nature of the process may be recognized only 
after the abdomen has been opened for the removal of a supposed ab- 
dominal, usually ovarian, tumor. In other cases severe symptoms may 
develop suddenly and progress rapidly, and directly call attention to the 



INFECTIOUS DISEASES. 



279 



probable tuberculous nature of the affection. A frequent early symptom 
is a sensation in the abdomen, either localized or diffused, rather of dis- 
comfort than of pain. Severe pain may be an early symptom, in which 
case it is associated with tenderness, and may be prolonged, with inter- 
missions of comparative comfort.- 

Irregular elevation of temperature is an important symptom, although 
there may be prolonged intervals of normal, perhaps subnormal, tempera- 
ture. The attacks of abdominal pain are likely to be accompanied with 
elevations of temperature, and both pain and fever are often associated 
with alterations in the size of the abdomen. 

The enlargement of the abdomen is due, at the outset, to the exuda- 
tion of liquid, which in the course of time may become so abundant as 
to produce considerable distention. The intestines may float freely, and 
a wave be transmitted throughout the abdomen as in ascites. The en- 
largement is to be partly explained by the presence of gas in the intes- 
tines, variations in the quantity of which largely account for temporary 
modifications in the size of the abdomen. With the formation of fibrin- 
ous and eventually fibrous adhesions the liquid exudation is usually 
diminished and often encapsulated, thus causing the circumscribed 
tumors already mentioned, which, according to the predominance of 
tubercles and exudation or of intestinal gas, are flat on percussion or 
present a modified, perhaps tympanitic, resonance. The fixedness and 
elasticity as well as the resonance of these tumors give satisfactory evi- 
dence of their nature and origin. They are thus not to be confounded 
with the resistant, sausage-shaped masses of thickened and shrivelled 
omentum or with the indurated products of a tubercular peritonitis to 
be felt on pelvic examination. 

As the disease progresses, digestive disturbances become especially 
conspicuous. There are loss of appetite, nausea, perhaps vomiting, and 
diarrhoea or constipation. The last may be so severe as to lead to a 
diagnosis of intestinal obstruction. Ultimately loss of flesh and strength 
becomes conspicuous, and is especially marked in those cases in which 
intestinal fistulae have arisen, or in which extensive tuberculosis exists 
elsewhere, especially in the lungs or the intestine. 

Diagnosis. — The frequency of a gradual onset of the disease and the 
latency of the symptoms have often made an early diagnosis difficult. 
This is conspicuously shown by the fact that in the majority of cases 
in which tubercular peritonitis has been discovered at a laparotomy a 
previous diagnosis of some other affection, particularly of an abdominal 
tumor or an ovarian cystoma, has been made. Ascites, chronic peri- 
tonitis with abundant effusion, and abdominal tumors are especially to 
be differentiated. For this purpose an appreciation of the etiology of 
the several affections is of importance. 

Ascites is simulated when there is abundant free fluid in the peritoneal 
cavity. In tubercular peritonitis, however, there may be a certain degree 



280 



GENERAL DISEASES. 



of abdominal pain and tenderness, more or less fever, even if slight, and 
frequent indurations, while in ascites jaundice or gastro-intestinal hem- 
orrhages and enlargement of the spleen are to be expected. 

Most cases of subacute and chronic general peritonitis of non-trau- 
matic origin, independent of antecedent acute peritonitis and cancer or 
sarcoma, are possibly of tubercular origin. Evidence of pre-existing or 
associated tuberculosis of the lungs, intestine, genitals, kidney, lym- 
phatic glands, or bones, also an associated pleuritic effusion, favors the 
tubercular nature of the peritonitis. If such evidence is lacking, a dif- 
ferential diagnosis between chronic tubercular peritonitis and chronic 
peritonitis with abundant serous effusion may be as impossible as is the 
differential diagnosis between chronic granular peritonitis and miliary 
tubercular peritonitis when based on the gross appearances alone after 
the abdomen has been opened, either during life or after death. Fortu- 
nately, this distinction is of little practical importance in treatment. 

A parovarian or a unilocular ovarian cyst may be differentiated with 
difficulty. The fluid from the former is sufficiently characteristic, while 
the growth of the latter is likely to be slower, with less disturbance and 
without emaciation and debility. Malignant disease of the peritoneum 
may closely resemble the graver forms of tubercular peritonitis, especially 
when tumor-like masses are present, and is to be differentiated by its 
more rapid progress and by the presence of probable malignant disease 
elsewhere, especially of some abdominal organ. 

Prognosis. — The mortality in cases of tubercular peritonitis has until 
recently been considered extremely high, most cases being thought to 
prove fatal within a year after the recognition of the disease. So exces- 
sive a death-rate was largely attributed to the existence of severe tuber- 
culous disease elsewhere, and to the complications, especially the intestinal 
fistulse, resulting from the abdominal disease. At the same time, cases 
have been recorded in which the exudation of supposed tubercular peri- 
tonitis has disappeared. In one instance the patient was alive three years 
later ; in another the patient died of general tuberculosis after two years ; 
in a third, as reported by Pribram, tubercles and characteristic bacilli were 
found at the end of a year and a half when laparotomy was performed for 
the removal of a parovarian cyst. Of late years frequent recoveries from 
assumed or assured tubercular peritonitis have been announced. Casinari 
states that of eight hundred and forty cases which have been reported 
two hundred and eight died, giving a mortality of about twenty -four per 
cent. The diagnosis of tubercular peritonitis, to be beyond criticism, 
demands the recognition with the microscope of Koch's bacilli or evi- 
dence of their presence by inoculation experiments. Such information 
has been possible only since 1882, and has been furnished in compara- 
tively few of the numerous reported instances of tubercular peritonitis 
cured by laparotomy. But the few indubitable cases, in addition to the 
experimental evidence furnished by Stchegoleff, make it evident that 



INFECTIOUS DISEASES. 



281 



under suitable conditions the prognosis of tubercular peritonitis may 
be favorable. It is generally recognized that the variety of tubercular 
peritonitis which presents the least danger is that with abundant serous 
exudation and latent symptoms. 

TUBERCULOSIS OF THE DUCTLESS GLANDS. 

Tuberculosis of the Spleen. — The spleen, like the liver, is a fre- 
quent seat of tubercles, the bacilli being brought by means of the blood 
or entering from the peritoneal cavity. In acute miliary tuberculosis 
thousands of tubercles may be present, which are at times with difficulty 
distinguished from the Malpighian corpuscles. The spleen is enlarged, 
moderately firm, of dark-red color. On section the pulp is increased and 
studded with innumerable grayish- white specks slightly projecting above 
the surface, as if the section were finely sanded. 

Chronic tuberculosis of the spleen occurs as cheesy nodules more or 
less rounded and varying in size from that of a grape-seed to that of a 
hazel-nut, the additional presence of miliary tubercles at the periphery 
indicating a x>rogressing stage. Fibrous adhesions are frequent between 
the spleen and the abdominal wall when the solitary tubercles lie near 
the surface of the spleen, and tubercles may be present in the adhe- 
sions. The demonstrable enlargement of the organ in acute miliary 
tuberculosis is so constant as to be a valuable diagnostic sign of this 
affection. 

Tuberculosis of the Lymph- Glands. — The lymph-glands are con- 
stantly diseased in tuberculosis. They are usually affected in virtue of 
tubercular changes in the regions from which they receive lymph, al- 
though they may become tuberculous without evidence of a pathological 
process in such regions. When one set of glands is affected, tuberculosis 
of other lymphatic glands is likely to follow. The glands oftenest dis- 
eased are the cervical, bronchial, and mesenteric ; but those in the axilla 
and the groins are not exempt. The occurrence of tuberculosis of the 
cervical glands as a sequence of chronic cutaneous inflammations of the 
face and scalp, of naso-pharyngeal catarrhs, and of carious teeth, suggests 
that glands inflamed from whatever cause are prone to become infected 
with the bacilli. In like manner, the presence of bronchial and mesen- 
teric tuberculous glands without evidence of pulmonary or intestinal 
tuberculosis indicates that irritations of the respiratory and intestinal 
tracts may be followed by the admission of the bacilli to the neighboring 
glands without the production of surface lesions. Local tuberculosis of 
any part of the body is likely to be speedily followed by tuberculosis of 
the nearest group of lymphatic glands. 

The bacilli of tuberculosis when lodged in a lymph-gland cause a 
productive inflammation, a lymphadenitis. Two varieties of this result 
occur, — the one, tubercular lymphadenitis, conspicuously characterized 
by the presence of visible and structural tubercles containing the bacilli, 



282 



GENERAL DISEASES. 



and the other, cheesy lymphadenitis, chiefly manifested by extensive 
necrosis of the gland with or without visible tubercles. The failure to 
discover with the microscope the bacilli in such glands does not contra- 
dict their tubercular nature, since the inoculation of guinea-pigs with the 
cheesy material is usually followed by the production of tuberculosis in 
them. 

In tubercular lymphadenitis the gland is moderately enlarged by an 
increase in the number of its cells. Miliary tubercles appear, increase in 
number, and become confluent and cheesy. Multiple nodules may thus 
form, and the gland eventually grow cheesy throughout. The individual 
tubercles may also undergo a fibrous transformation, and the entire gland 
become indurated by the increased formation and contraction of fibrous 
tissue. 

In cheesy lymphadenitis the glands are swollen, perhaps to the size 
of a pigeon's egg, and on section are of a reddish-gray color and some- 
what translucent. The enlargement is due to an increase in the number 
of the large and small lymphocytes, and giant cells may form ; but miliary 
tubercles are lacking, the process being one rather of diffuse than of 
circumscribed inflammation. A necrosis of the cells takes place, and the 
enlarged gland in the course of time is transformed into a homogeneous 
cheesy mass, whilst softening or calcification may subsequently occur. In 
the former the evacuation of the cheesy detritus takes place through the 
skin or into a neighboring cavity or hollow organ or into the blood-vessels 
or lymphatics. The discharge through the skin produces fistulse with 
tuberculous walls, and if the bronchi are perforated a pulmonary tuber- 
culosis results. Evacuation into the intestine may give rise to intestinal 
tuberculosis, while the passage of the contents into a serous cavity results 
in a pericarditis, pleurisy, or peritonitis. The escape of the softened 
cheesy material into a blood-vessel or into a large lymphatic, as the tho- 
racic duct, is a most important cause of general tuberculosis, and such 
a result offers a direct demonstration of the tuberculous nature of the 
softened lymph-gland. Calcification of the cheesy lymph-gland repre- 
sents an arrest of the process, the lime salts being deposited in the 
cheesy material of the previously enlarged gland, which is also fibrous 
and atrophied. 

Symptomatology. — Tuberculous adenitis is most common in children, 
but may be manifested at any time in life when a local tuberculosis in the 
affected region occurs. The symptoms vary in accordance with the num- 
ber of glands involved and the rapidity of the infection. Osier mentions 
a case of general tubercular lymphadenitis, with a continued elevation of 
temperature extending throughout a year, in which enlarged and cheesy 
glands were the sole significant lesions. As a rule, the enlarged lymph- 
glands produce but little local disturbance. They remain quiescent, or 
soften and are evacuated, the fistulas also often giving little or no trouble. 
Persons with tuberculous glands are likely to suffer from catarrhal and 



INFECTIOUS DISEASES. 



283 



cutaneous affections and from digestive disturbances. They are apt to 
be anaemic and debilitated, especially early in life, but, except in case 
of febrile disturbance, are comparatively free from discomfort. The 
deformity is usually more distressing than the disease. 

Diagnosis. — Enlarged lymph-glands are to be recognized as tuber- 
culous only when the bacilli of tuberculosis are found in them or when 
inoculation from them produces tuberculosis in animals. The tubercu- 
lous nature of the enlarged lymph-gland is to be inferred when evidence 
of a local tuberculosis is found in the vicinity, as tuberculous ulcers 
of the skin or of the pharynx, or when the bacilli of tuberculosis are 
found in pus from the middle ear or from carious bone or teeth. The 
tubercular nature of visible enlarged glands may also be inferred if evi- 
dence of tuberculosis is found elsewhere, as in the lungs, intestine, serous 
cavities, or uro-genital apparatus. 

Prognosis. — The presence of tuberculous glands is always a source 
of anxiety, from the liability of the extension of the infection from gland 
to gland, or to some important organ, or throughout the body. Glandular 
tuberculosis, when limited, may be recovered from, either as a result of 
treatment or in consequence of the softening and evacuation of the tu- 
berculous gland or of its induration and calcification. 

Tuberculosis of the Thymus and Thyroid Glands. — Eecorded 
instances of tuberculosis of the thymus gland are very rare. According 
to Jacobi, who reports three cases of general tuberculosis in which the 
thymus was diseased, there was but one of isolated primary tuberculosis, 
that of Demme. Miliary tubercles alone may be present, also cheesy 
nodules with miliary tubercles at the periphery. 

The thyroid gland may also be the seat of miliary or nodular tuber- 
culosis, in both instances associated with the presence of tuberculosis 
elsewhere. There are no known symptoms resulting from tuberculosis 
localized in the thymus or the thyroid. 

Tuberculosis of the Suprarenal Capsules. — This affection is usually 
chronic, and may exist alone, although generally associated with tuber- 
culosis of other organs. Its chief clinical interest is due to its frequent 
presence in Addison's disease. (See page 41.) 

TUBERCULOSIS OF THE VASCULAR SYSTEM. 

Tuberculosis of the Heart and Blood- Vessels. — Miliary tubercles 
as part of an acute miliary tuberculosis are rarely found in the heart, but 
pericardial tuberculosis is often continued into the myocardium, in which 
cheesy patches and nodules may thus be produced. Gummata of the 
myocardium have repeatedly been mistaken for cheesy tubercles, in virtue 
of similar gross appearances. The bacilli of tuberculosis have been 
found in the vegetations of acute endocarditis in cases of chronic pul- 
monary tuberculosis. It is not unlikely in such cases that the bacilli 
lodge in vegetations due to other causes. 



284 



GENERAL DISEASES. 



The arteries are frequently invaded by the bacilli from tubercular 
processes in the vicinity, and miliary tubercles in the adventitia of the 
arteries of the pia mater are a constant feature in tubercular meningitis. 
Tubercles are also to be found projecting from the intima of the pul- 
monary artery and even from that of the aorta in cases of chronic tuber- 
culosis, there being no tubercular lesions in the vicinity. Mallory has 
observed the bacilli in the base of aortic ulcers and between the laniellsB 
of the elastic coat. It is probable that the tubercles of the intima of 
arteries become necrotic and softened and thus aidj in the dissemination 
of bacilli. Tuberculosis of the veins also may occur, the bacilli being 
either transferred from the immediate vicinity when a tubercular inflam- 
matory process reaches the wall of the vein, or entering directly from the 
blood, the latter probably being the source of the miliary tubercles which 
project from the intima in general tuberculosis. The relation of such 
venous tubercles to general tubercular infection is the same as in the case 
of arteries, the admission of the bacilli into the veins being the more 
frequent. 

TUBERCULOSIS OF THE BRAIN AND SPINAL CORD. 

Cerebral tubercles as distinguished from meningeal tubercles occur in 
the form of cheesy nodules, single or many, varying in size from that of 
a cherry-stone to that of a walnut. The larger, solitary tubercles more 
often occur in the cerebellum, pons, and cerebral peduncles. The mul- 
tiple nodules are usually intimately connected with the pia mater of the 
convexities, and are essentially a globular variety of chronic meningeal 
tuberculosis, although the more frequent manifestations of the latter are 
cheesy plates, at the base or upon the convexities, oftener in the former 
situation. The presence of miliary tubercles at the periphery or in the 
vicinity of such cheesy formations, or the discovery in the latter of the 
characteristic bacilli, is indicative of the nature of the lesions, whose gross 
appearance often suggests that of sarcoma or gumma. This difficulty of 
diagnosis is especially marked in the case of the solitary tubercle, which 
may increase in size periodically, with intervals of quiescence, miliary 
tubercles being present at the periphery during the stage of growth 
and being absent at a later period. Cerebral tubercles are more fre- 
quent in children than in adults, and are usually associated with tuber- 
cles elsewhere. They are of probably hematogenous origin, except in 
those cases in which the infection is extended from a chronic tubercu- 
losis in the immediate vicinity, as in nasal or auditory tuberculosis. 

Tuberculosis of the spinal cord also occurs in the form of cheesy 
nodules, which may long remain latent, although gradually increasing in 
size until significant symptoms are present. The clinical characteristics 
of tuberculosis of the brain and spinal cord are essentially those of tumors 
of these organs, and are to be found in the consideration of the latter 
subject. 



INFECTIOUS DISEASES. 



285 



TUBERCULOSIS OF THE BONES AND JOINTS. 

Tuberculosis of the bones throughout the body is a very frequent 
accompaniment of acute miliary tuberculosis, the tubercles being present 
in the marrow as miliary granules, which often, though with difficulty, 
are recognized without the aid of the microscope. More important is 
the occurrence of localized chronic tuberculosis, osteomyelitis tuberculosa, 
which takes place particularly in the vicinity of joints, especially of the 
lower extremities. The frequent association with tubercular arthritis 
suggests that the bacilli may enter the bone- marrow from the joint, 
although the absence of disease of the joint in other cases is evidence 
that the infection of the bone-marrow likewise takes place through the 
circulation. In chronic local tuberculosis of the bones extensive hyper- 
plasia and necrosis of the marrow are present. The trabecule become 
disintegrated, fragments of bone of various size are sequestered, and 
cavities arise eventually communicating with the surface and leading to 
the formation of fistulaB. With the occurrence of chronic tubercular 
osteomyelitis the periosteal growth of bone is often increased and aids 
in the retention of sequestra in the interior of the shaft. Such bone 
tuberculosis forms a frequent basis for cranial and vertebral caries and 
for the carious and club-shaped bones of the extremities. 

Tuberculosis of the joints may result from the entrance of bacilli into 
the joint from the synovial membrane, or may be due to the extension to 
the joint of a tubercular osteomyelitis. Large and small joints may be 
affected, especially those of the lower extremities. The synovial mem- 
brane is thickened, reddish-gray, and translucent, and contains minute 
gray or yellow miliary tubercles. As the disease progresses and the 
tubercles become caseous and softened, concurrent destruction and pro- 
liferation of the synovial membrane take place. The ligaments and the 
surrounding tissue are thickened and fibrous, tuberculous fistulse extend 
from the joint towards the skin, and the familiar white swelling results. 
Destruction of the cartilage and adjacent bone may occur, and sinuses 
are formed which lead, often through spongy bone, towards and into the 
diseased joint. The articular cavity may contain much or little exuda- 
tion, which is serous, fibrinous, or purulent. The tuberculous nature of 
osteomyelitis and arthritis is rendered positive by the discovery of the 
typical bacilli in the exudation or in the diseased parts ; but the clinical 
history of the cases suggests that all are not due to tuberculosis, and the 
bacilli have repeatedly been sought for in vain. 

Tuberculosis both of bones and of joints is more frequently found in 
the young, especially in children, and its further consideration belongs 
to surgery. 

SCROFULA. 

The intimacy of relation between scrofula and tuberculosis is such 
that many writers regard them as absolutely identical ; but scrofula as 



286 



GENERAL DISEASES. 



distinguished from tuberculosis is rather indicative of a state of the 
tissues and their relation to nutritive processes than of an infectious 
disease. The term was originally invented on account of the resem- 
blance of the swollen neck of affected individuals to that of swine, 
scrofa. Such swelling was eventually found to be chiefly due to en- 
largement of the lymphatic glands or to an increase in the size of the 
thyroid gland. The enlargement of the lymphatic glands proved to be 
due to a variety of causes, but cheesy conditions were most frequently 
observed. The cheesy glands were called scrofulous, and similar cheesy 
appearances found elsewhere in the body also were designated scrofu- 
lous, hence scrofulous kidney and scrofulous testicle, and were regarded 
as the manifestations of a like condition of the body, the scrofulous 
diathesis or constitution. The enlarged thyroid gland received the term 
struma, and English writers were accustomed to use strumous and scrof- 
ulous as synonymous. As it appeared, especially in children, that cuta- 
neous eruptions, obstinate catarrhs, and inflamed bones and joints were 
frequently associated with enlarged cheesy glands, such affections were 
regarded as scrofulous, and thus arose the terms scrofulous lichen, scrof- 
ulous ulcers, scrofulous ophthalmia, scrofulous ozaena, scrofulous bones 
and joints. 

From the frequent association of the cheesy alterations with tubercles 
of various size and appearance the cheesy conditions eventually were 
regarded as a manifestation of tuberculosis. Thus scrofula and tuber- 
culosis became identified. Virchow, however, showed that the cheesy 
appearances might be the result of various pathological processes, and 
Koch demonstrated that the presence of the bacillus of tuberculosis is 
the essential characteristic of tuberculous material. Although much 
cheesy material contains this bacillus or produces tubercle when inocu- 
lated, exceptions frequently arise. By those who would identify scrofula 
and tuberculosis it is held that positive results follow inoculation only 
when a certain number of bacilli are present, and the older the cheesy 
material the less numerous the bacilli ; but it is maintained, on the other 
hand, that more bacilli are at times to be found in old than in fresh 
cheesy material. It is also argued that the negative results of inoculation 
are attributable to an enfeebled virulence of the bacilli, — a view which 
receives support from the experiments of Arloing, who found that rabbits 
were insusceptible to the inoculation of cheesy material which infected 
guinea-pigs, although the virus from such guinea-pigs, passed through 
successive series, became so increased in virulence as to produce tuber- 
culosis in the rabbit. It is furthermore maintained that the scrofulous 
constitution, if not the scrofulous lesion, is due to the early lodgement 
in the tissue of the bacilli of tuberculosis. In favor of this view are the 
discovery of the bacilli in foetal blood and the production of tubercu- 
losis by the inoculation of blood from the umbilical vein of the infants 
of tuberculous mothers. Cheesy nodules containing bacilli have like- 



INFECTIOUS DISEASES. 



287 



wise been found in the viscera of an infant so young as to make proba- 
ble the prenatal origin of these nodules. 

Since cheesy degeneration is not due to tuberculosis alone, and since 
the bacilli of tuberculosis are not present in all cheesy material, it is 
obvious that caseation is not absolute evidence of tuberculosis. In cer- 
tain so-called scrofulous eruptions of the skin, lichen, for example, and 
scrofulous catarrhs, notably conjunctivitis, the bacilli of tuberculosis are 
absent : hence so-called scrofulous inflammations are not necessarily 
tuberculous. The question of the identity of scrofula and tuberculosis 
is, therefore, to be regarded as still open. There is to be recognized a 
condition of the body which Yirchow has defined as a feeble power of 
resistance of the tissues and a persistence of the disturbances in them. 
The pathological processes and products are to be found in the skin, 
mucous membranes, bones, and joints, and are usually associated with 
chronic enlargement of the lymph-glands. These pathological products 
are prone to become invaded by the bacillus of tuberculosis, which finds 
in them suitable conditions for its growth and dissemination. The term 
scrofula is thus to be applied to those individuals who through inheri- 
tance or by exposure to faulty hygienic surroundings acquire such a 
vulnerability of the tissues that trivial causes produce persistent lesions, 
and in whom exposure to tubercular infection is frequently if not always 
followed by the harboring and propagation of its bacillus. The scrofu- 
lous person thus is one who is prone to become tuberculous in virtue 
of vulnerable tissues, but who is not tuberculous until infected by the 
bacillus of tuberculosis. 

Etiology. — This vulnerability of tissues is of both congenital and 
acquired origin. Congenital causes are to be found in scrofulous or tu- 
berculous parents, or in those enfeebled by severe chronic diseases, as 
syphilis, cancer, or nephritis, or by the abuse of alcohol. Early and late 
marriages and those of near blood relations have been considered im- 
portant in etiology. Causes of acquired vulnerability are bad air, poor 
food, insanitary dwellings, the crowding together of -children in insti- 
tutions, and insufficient attention to hygiene. Although scrofula is 
more common among the poor, it is not limited to tliem. The manifes- 
tations of the condition often appear in early infancy, but usually become 
pronounced in childhood. 

Morbid Anatomy. — The products of chronic inflammation of the skin 
and mucous membranes, of the lymphatic glands, and of the bones and 
joints are the lesions likely to be present in scrofula. Enlargement of the 
lymph-glands, especially when associated with cheesy degeneration, has 
always been regarded as the essential anatomical feature of scrofula. It is 
obvious that this view is not absolutely correct, and in the light of our 
present knowledge the scrofulous as distinguished from the tuberculous 
lymph-glands, whether caseation is present or absent, are those in which 
the bacilli are absent, as indicated by the results of inoculation as well as 



288 



GENERAL DISEASES. 



by the microscopical examination. Practically, when caseation is present 
the scrofulous glands have become tuberculous. TJie scrofulous lesions 
of bones are especially to be found in the vertebrae and the long bones 
of the extremities. They are manifested by an osteomyelitis which pro- 
gresses with destruction of the bone, the abscesses extending towards dis- 
tant parts, as in the prevertebral abscess of spinal caries. The evacuation 
of the pus leads to the formation of fistulse and sinuses in the vicinity of 
or at some distance from the diseased bone. In like manner a scrofu- 
lous inflammation of the joint is represented by a chronic thickening of 
the tissues, destruction of the cartilage, and fungous granulations. In 
many cases, however, of chronic osteomyelitis and arthritis caseation of 
the inflammatory product occurs, and tubercles and bacilli are present : 
hence the distinction between a scrofulous and a tuberculous joint de- 
pends also upon the results of the search for the bacilli. The recovery 
from such inflamed joints as well as from a scrofulous osteomyelitis offers 
suggestive evidence of the absence of bacilli, as the persistent progress 
of destruction implies their presence. In the latter event both the 
scrofulous joint and the carious bone may be considered to have become 
probably tuberculous. 

Symptomatology. — Among the earliest symptoms suggestive of 
scrofula are cutaneous inflammations, especially lichen, which is char- 
acterized by clusters of miliary, red or reddish-yellow papules in the 
vicinity of the hair-follicles, especially upon the chest and the abdomen. 
The rash may persist even for years, new papules being formed as those 
earlier formed disappear. Chronic eczema, both moist and squamous, 
is frequent upon the scalp, face, and ears, and the pustules of impetigo 
are to be seen upon the face and extremities. Lupus and scrofuloderma, 
formerly regarded as manifestations of scrofula, are known to be tuber- 
cular lesions. Subcutaneous abscesses often occur, either as complica- 
tions of cutaneous inflammations or of independent origin, and are prone 
to remain quiescent for a long time, the pus being eventually absorbed 
or evacuated. 

Catarrh of the mucous membranes is common and often persistent. 
Conjunctival catarrh tends to become granular, and is often associated 
with eczema of the lids, inflammation and opacity of the cornea, and 
pannus. The nasal catarrh is obstinate, and produces copious secre- 
tion, which either macerates the skin of the nostrils and the upper lip, 
causing redness and swelling and often eczema of the lip, or forms crusts 
at the nasal openings. Chronic or recurrent swelling of the tonsils and 
enlargement of the pharyngeal lymph-follicles are conspicuous features. 
The pharyngeal catarrh extends to the middle ear, often resulting in 
perforation of the tympanum and extension to the mastoid cells, with 
continuous or recurrent discharge from the meatus which frequently 
continues into adult life. Catarrh of the respiratory mucous mem- 
brane leads to repeated attacks of laryngitis, tracheitis, and bronchitis, 



INFECTIOUS DISEASES. 



289 



while the catarrhal infectious diseases, as measles, influenza, and whoop- 
ing-cough, tend to the production of broncho-pneumonia. Catarrh of 
the stomach and intestines is also of frequent occurrence. 

Swelling of the lymph -glands is dependent upon cutaneous or catarrhal 
inflammations or affections of the bones and joints : hence the glands 
affected are those nearest the seat of the inflammation, and frequently 
several are implicated. The glands oftenest concerned are those beneath 
the jaw and in the neck. The axillary and inguinal glands are enlarged 
when inflammations of the trunk or extremities occur, and the bronchial 
and mesenteric glands become inflamed in consequence of catarrh of the 
bronchi and intestine. The glands at first form lumps of the size of 
beans, but may be as large as walnuts. They are neither painful nor 
tender, and may persist for years without undergoing further changes. 
With a recurrence or continuance of the affections of the skin or mucous 
membranes they further enlarge. They may subsequently shrink, but 
are likely to grow until they form tumors, sometimes of considerable 
size, which become cheesy, calcified, or softened. When the softened 
material is evacuated, sinuses are produced, which heal with difficulty 
and usually with the formation of extensive scars. In such cases the 
scrofulous glands are tuberculous, but the quiescent glands are associ- 
ated with no symptoms in virtue of which the presence of the bacilli of 
tuberculosis can be recognized. 

Affections of the bones in scrofula are those of a chronic character 
tending towards caries. Although the most frequent cause of caries of 
the bone is tuberculosis, in a scrofulous person the infectious or traumatic 
causes may produce an osteomyelitis not to be distinguished from that 
due to tuberculosis except by the absence of the bacilli of tuberculosis. 
A carious bone in the scrofulous person is apt to become tuberculous 
even if it were not so from the outset. If the osteomyelitis arises in 
the vicinity of a joint, the joint frequently is secondarily involved. 
The inflamed joint of the scrofulous person is usually announced by 
vague pain, impaired mobility, and a gradually increasing swelling. 
Such joints are likely to become tuberculous, in which case the per- 
sistent oedema of the surrounding tissues is a suggestive symptom. The 
especial consideration of the osteitis and arthritis of scrofulous persons 
belongs to surgery. 

Two types of scrofulous children are usually described, although it is 
generally considered that they are not sufficiently constant to be regarded 
as characteristic. The one is represented by a stunted growth, coarse, 
flabby, clammy skin, thick nose and lips, and a swollen abdomen. Men- 
tal and physical action are characterized by slowness and deliberation. 
Such children are prone to cutaneous and catarrhal affections. The other 
type includes the tall children, usually blondes, with small bones, thin, 
pale skin, and prominent veins. The eyes are large and expressive, and 
the cheeks readily flush. These children are lively both in mind and in 

19 



290 



GENERAL DISEASES. 



body. Febrile disturbances are frequent in them, and they are especially 
likely to become tuberculous. 

Diagnosis. — The suggestion of scrofula is presented by children with 
the characteristics last mentioned, and especially when the etiological 
causes exist ; the diagnosis of scrofula is to be made when the previously 
mentioned recurring or chronic affections of the skin, mucous membranes, 
lymph-glands, bones, and joints are present, and the bacilli of tubercu- 
losis are absent. Some of the manifestations of congenital syphilis may 
be mistaken for those of scrofula, but the cutaneous manifestations of 
syphilis are more general, the tendency to ulceration is more frequent, 
the enlargement of the glands is less considerable, and the affections 
of the bones and joints are of early occurrence. 

Prognosis. — Becovery from scrofulous lesions, even from those of 
bone, is frequent, although the tendency to scrofulous inflammations 
usually persists till puberty. The especial danger is the liability to 
tubercular infection, which often occurs before puberty and may manifest 
itself at a later period in life. The prognosis in the individual case be- 
comes the more serious the more permanent the nature of the lesions : 
hence enlarged glands, caries of the bone, and chronic arthritis have a 
graver prognosis than cutaneous eruptions or catarrh. That the more 
serious lesions are not hopeless is evidenced by the numerous persons 
who have reached middle life despite deforming scars of the neck, cur- 
vature of the spine, and stiff joints originating during a scrofulous 
childhood. 

Prophylaxis. — The prophylaxis of tuberculosis may be either from 
the point of view of the individual already suffering or from that of the 
person free from the infection. In order to prevent himself from be- 
coming a centre of infection, and also to diminish the possibility of rein- 
fection of himself, the tuberculous person should destroy by burning or 
boiling all discharges from diseased parts, whether such parts be internal, 
as the lung or the bowels, or external, as open glands or joints. Local 
cleanliness is essential, and in phthisis it is important that the sputa be 
not swallowed, but expectorated and immediately destroyed. Portable 
spit- cups are in the market : or small pieces of rag may be used, put in a 
special receptacle, and finally burned. 

The tuberculous subject should never sleep in the same bed with an- 
other person, and absolute cleanliness of the person should be enjoined ; 
the occupied apartment should have a hard- wood floor, with mats instead 
of carpets, and should be thoroughly scrubbed at short intervals. If 
these precautions be observed, and if the apartment be at all times well 
ventilated, the risk to a healthy person involved in nursing a consump- 
tive will be very slight. In a family, however, in which the tendency to 
tuberculosis is strong, this risk is appreciable. 

From the point of view of the non-infected person with an hereditary 



INFECTIOUS DISEASES. 



291 



tendency to the disease there are two desiderata : first, to increase the 
resistive power of the tissues ; secondly, to avoid infection with bacilli. 
Of these the most important is the first mentioned, at least if the in- 
dividual is to live within the confines of civilization, since the tubercle 
bacillus is so universally present as to make escape from it hopeless. At 
the same time it is important to avoid inoculation as far as possible, and 
the person who has a strong hereditary tendency to tuberculosis should 
shun unnecessary exposure to the contagium : thus, a physician should 
not take a resident position in a consumptive hospital ; a nurse should 
decline tubercular patients. There can be no doubt that, especially in 
our large cities, there are houses and rooms in houses which are infected 
with the bacillus of tuberculosis. A person with lack of resistive power 
should never live in a room or even in a house which has been inhabited 
by a tubercular patient, unless such apartment or house has been cleansed 
and disinfected in a most thorough manner. 

It has been demonstrated that the tubercle bacillus may be trans- 
mitted to the human being with animal food, yielded by tubercular 
animals. The danger of infection from tubercular milk is greater than 
from tubercular meat, evidently because before it is eaten meat is almost 
uniformly subjected to a sufficient temperature to kill the bacillus. The 
inspection of milk and of meat by municipal authorities in large cities 
ought to be, but is not, sufficiently rigorous to guarantee immunity ; and 
precaution should be taken by the susceptible individual against tuber- 
culous foods, especially to see that the milk habitually used is obtained 
from healthy cows. 

The child with hereditarily feeble resistive powers should from the 
beginning be brought up with the purpose of developing the muscular 
and circulatory system and of obtaining that vitality which is given by 
continuous life in the open air. At the same time it must be carefully 
guarded from the various infectious diseases, especially such as measles, 
which have a tendency to provoke catarrhal inflammations, and it should 
be continually watched to prevent the development of mucous membrane 
catarrhs, which experience has shown have a pronounced tendency to 
aid in the development of tuberculosis. Obstruction of the nose and 
throat by malformations, adenoid glands, or enlarged tonsils should be 
promptly relieved by surgical or other treatment. The clothing should 
be warm, woollen in winter : it is the height of folly to attempt to 
harden such a child by insufficient clothing and exposure. Habitual cold 
bathing is excellent. The food should be abundant, simple, nutritious, 
largely but not altogether farinaceous, with a full supply of milk, and, 
if possible, of fats. Almost invariably the child can be brought to like 
cod-liver oil, and advantage is often gained by making this fat an habitual 
article of diet in cold weather. 

In selecting a climate the question of degree of temperature is a minor 
one ; that of moisture and equability of temperature is dominant. A 



292 



GENERAL DISEASES. 



dry equable climate is always preferable. Dry cold is not dangerous, 
and is, indeed, preferable to enervating warmth. 

Prolonged life in high mountainous regions during childhood, if asso- 
ciated with habits of exercise, has a distinct tendency to develop the 
lungs and heart, and is very beneficial. When there is any special 
failure in the chest development, gymnastic exercises directed to the 
development of this part of the body may be very useful ; but no in-door 
exercise will take the place of out-door work ; and it is not probable that 
any artificial system is better than or even equal to the natural gymnastics 
of an active child. Eunning up and down mountains, herding goats and 
sheep, following the chase, fishing mountain streams, — these are the 
methods of restoring vitality to an exhausted family stock. It is affirmed 
by recognized authorities that a long-continued life at high altitudes so 
greatly increases the respiratory movements as to cause dilatation of the 
air-vesicles and a permanent increase in the size of the chest, which 
is a great disadvantage when such persons attempt to live at the sea- 
level. If this be correct, it constitutes no reason against bringing up the 
hereditarily feeble upon the mountains, but is a strong one for keeping 
them there during their after adult life. The out- door life is the one 
dominant feature : this must be insisted upon when the individual is 
forced to take what he can get, not being able to get that which is best. 
Thus, a seafaring life entered early, though less beneficial than a moun- 
tain life, is much better than a city life, provided its hardships are not 
too great. If the subject is forced to live in the city and earn his daily 
bread, the safest occupation is probably that of a car- driver or a motor- 
man, with its continual open-air exposure and partial protection from 
the elements. 

The habitual use of any drug is probably more injurious than bene- 
ficial, but, when there is any excessive susceptibility of the mucous mem- 
brane, continuous courses, spreading over months, of minute doses of 
arsenic are certainly worthy of trial. The arsenic-eaters of the Styrian 
Alps, if accounts can be trusted, are remarkable even among moun- 
taineers for their pugnacity, their endurance, and their long-windedness. 

Treatment. — Acute general tuberculosis always ends fatally, and, as its 
course cannot be distinctly modified by any known method of treatment, 
the effort of the physician should be especially directed to the obtaining 
of euthanasia. All possible moral support should be given to the patient. 
Disagreeable drugs and disturbing agencies should be sedulously avoided 
unless the relief of pain by them would be distinctly greater than the 
suffering produced by them : thus, a blister by relieving a pleuritic pain 
may be a great relief. Morphine and other narcotics should be used 
without hesitation to relieve suffering. The general course of treatment 
must be symptomatic and palliative. 

In the treatment of chronic tuberculosis it is essential that the physi- 
cian free his mind from the thought that the disease is necessarily fatal, 



INFECTIOUS DISEASES. 



293 



so that he may be able to impart hopefulness to the patient under his 
care, — since to the ordinary individual there is no more depressing agent 
than the belief in oncoming death. 

The first indication for treatment is removal of the infected part, 
when possible. In the case of glands and other parts which can be 
destroyed by the surgeon's knife, no time should be lost in dallying 
when once the diagnosis has been made clear. Unfortunately, in the 
larger proportion of cases excision of the affected part is impossible, 
so that the case must be treated entirely medically. The growth of sur- 
gery, however, has gradually widened the scope of surgical treatment. 
Thus, it is probable that tubercular peritonitis should be considered a 
local surgical disease. 

Many attempts have been made to destroy colonies of bacillus by 
local or other medicinal treatment. In external tuberculosis the appli- 
cation of concentrated germicides or the free use of iodoform may be of 
service, but in internal tuberculosis these local agents are never of any 
value. Creosote, carbolic acid, and other drugs have been administered 
by the mouth, but when so given have no specific action on the tuber- 
cular bacillus. No known dose of any germicide which can be borne by 
the human system has any distinct power in even inhibiting the growth 
of the tubercle bacillus when once lodged in the body. 

At one time extraordinary hopes were excited by the publications of 
Koch, — hopes which were, however, entirely beyond what ought to have 
been reasonably expected from Koch's own assertions. It is now known 
that the tuberculin of Koch was an impure toxin ; or, in other words, 
that it was a poisonous agent produced during the growth of the tuber- 
cle bacillus, the cause of the hectic fever and many of the constitutional 
symptoms of phthisis. It was stated by Koch that the hypodermic in- 
jection of tuberculin in the tubercular patient would produce a febrile 
reaction, and at the same time would soften all tissues containing the 
tubercle and lead to the throwing off of both tissues and parasite. 
These assertions are correct, but the changes do not benefit the patient. 
If the tuberculin or tubercle-toxin be injected into the normal indi- 
vidual in the dose recommended by Koch, no distinct symptoms usually 
result j if, however, a certain amount of toxin be already in the tissues 
about the bacilli and in the blood, the addition of the amount of toxin 
used will be sufficient to bring about a hectic fever, — i.e., febrile reac- 
tion, — and also to injure or to kill the tissue which is in immediate 
contact with the bacilli and already nearly saturated with toxin. The 
treatment, however, does not kill the bacilli, but simply liberates them 
by destroying the lung or other part in which they are situated. It 
puts the organisms in an excellent position for entrance into blood- 
vessels or lymphatics, and in this way has frequently led to a dissemi- 
nation of the bacilli and to a consequent conversion of a localized into 
a generalized tuberculosis. It is possible that in the future a tubercular 



294 



GENERAL DISEASES. 



antitoxin may be produced, but, as tuberculosis is not a self-limited dis- 
ease which produces an immunity, the prospects for success with its 
antitoxin do not seem brilliant. 

As at present we have no known method of directly attacking the 
bacilli in internal tuberculosis, the indications in the treatment of the 
local chronic forms of the disease are — first, to increase the general nu- 
trition and the resistive power of the individual ; second, to reduce to a 
minimum the local irritation and changes produced by the bacillus at 
the seat of infection ; third, to combat constitutional symptoms as they 
arise. 

First Indication. — The method of meeting the first of the indications 
just spoken of must vary with the stage and condition of the tubercular 
patient. In the advanced disease absolute rest in the open air in a 
mild climate may constitute the chief measure which can be adopted with 
advantage, but in the following discussion it will be considered that the 
subject is in the earlier stages of the disease, with only a moderate amount 
of local disease in the lung. Under these circumstances high feeding, 
exercise, and life in the open air, with as much sunshine as possible, are 
the chief agencies with which the tendency to disease must be combated. 
The food should always be simple, thoroughly well cooked, palatable, 
the most nutritious and digestible that can be obtained, with a fair pro- 
portion of farinaceous articles, very little sugar, and a large amount 
of fats. It is a matter of the utmost importance, however, not to over- 
feed the patient, — that is, not to give more food than can be digested. 
Vegetable fats are useful, but are probably inferior to animal fats. Sweet 
oil is an excellent food, but cod-liver oil is preferable. In the selection 
of fats, as of other foods, the question of digestibility is dominant, and 
in the use of cod-liver oil it is essential to see that no more is taken than 
can be absorbed without difficulty, this being the only limit to the amount 
of oil to be ingested. Alcohol may be considered under these circum- 
stances as a food, and is of the greatest value ; taken in large quantity, 
however, it becomes a deadly poison, and in tuberculosis, as in all other 
forms of chronic disease, overshadowing the use of alcohol is always the 
danger of the formation of the alcoholic habit. The judgment of the 
physician must be applied to the individual case. When the digestion is 
strong, malt liquors are often preferable to spirits ; but when there is any 
feebleness of the digestive organs, whiskey, brandy, or other distilled 
liquor is superior to either wines or malt liquors. Both for physical and 
for moral reasons, the alcoholic drink should always be given with food, 
and never in such amounts as to get its narcotic effect. An excellent 
combination is with cod-liver oil : thus, half a fluidounce each of the two 
substances may be given together after meals. It is essential that the 
patient be instructed never to use alcoholic liquor as a stimulant against 
the ever-recurring feeling of exhaustion. 

In prescribing exercise the points to be borne in mind are that the 



INFECTIOUS DISEASES. 



295 



exercise should be regular, day after day, with no paroxysms of excess 
to be followed by hours of exhaustion. It should never be violent, but 
should be continuous ; it may be adapted to the individual needs in 
developing the chest or other part, but always should be, if possible, 
in the open air, and always should be kept within the strength of the 
patient: slight tire producing quietness and sleep is advantageous, ex- 
cessive tire is very injurious. Continuous life in the open air is of the 
utmost importance ; even in the advanced stages of phthisis life will be 
protracted and made more comfortable by having the bed of the patient 
from sunrise to sunset on a porch or in the open air, if the temperature 
be suitable. 

The choice of climate for a patient is a most important part of the 
treatment. Usually the first decision to be made is whether the patient 
shall or shall not go away from home. The proper rule is, the milder and 
apparently more insignificant the local disease the more important the 
seeking out of a suitable climate, because the more is to be hoped from 
climatic treatment. If both apices are involved, the chances of life are 
so reduced that the physician is hardly justified in urging a change 
of habitation at every sacrifice. If with the involvement of each lung 
there be softening and formation of cavities, or if there be wide-spread 
tubercular infiltration with softening in one lung, change of climate 
can only be expected to give relief ; and whether it should or should 
not be sought must depend upon the environment and circumstances 
of the patient. In such a case removal to a mild climate not too far 
from home is often preferable to choosing a more distant though more 
salubrious region. 

In selecting for a patient the best possible region the individual pecu- 
liarities must be carefully studied. We have known tubercular patients 
whose only comfort and progress towards health were found in continu- 
ous life at sea. In the great majority of cases, however, a dry, equable 
climate, with abundant brilliant sunshine and pure air, constitutes the 
desideratum. The temperature and the character of the air must be 
such that the patient can be out of doors the whole time of daylight j and 
if the day and night can be spent practically out of doors the chances are 
much better. The climate in the Eastern United States which best suits 
the majority of cases is that of the Adirondacks ; Florida is too damp, 
enervating, and malarious in most of its parts for the ordinary case of 
incipient phthisis ; the high sand-ridge in the centre of the State is the 
best situated, but is probably inferior to the pine district of Southern 
Georgia. The high mountain districts of North Carolina rank next to 
the Adirondacks, and are even superior in those cases in which there 
is a tendency to feebleness in the heat-making function. If a patient 
feels the cold of the Adirondacks, Asheville is preferable ; or the win- 
ters may be passed in Asheville and the summers in the Adirondacks. 
Southern California in some of its parts is undoubtedly a good climate, 



296 



GENERAL DISEASES. 



but we believe it to be inferior to the central arid tract in the United 
States commencing in San Antonio, Texas, and running north to Colorado 
and Arizona. 

The height of the locality above the sea is a serious consideration to 
the consumptive. Although individual peculiarities here, as elsewhere, 
are important, the majority of tubercular patients will do best at a 
height of from three to six or even seven thousand feet above the sea. 
Among the modifying influences in regard to altitude is the tendency 
of the patient to hemoptysis : when this exists a rapid ascent to a con- 
siderable height greatly increases the danger of bleeding. It is prob- 
able that this is due to the extension of the air-vesicles by the increased 
efforts at respiration produced by the altitude. The very cause of the 
benefit of the altitude becomes the source of danger. Hemorrhagic cases 
should therefore begin their life in the arid tract at a low elevation. 
Again, in the northern portion of this region, and especially in the 
higher elevations, the cold is severe in winter ; on the other hand, in the 
San Antonio region the summer heat is excessive. It is plain that the 
first selection of a climate depends upon the character of the case and 
the season of the year. In the winter it is usually preferable to send the 
patient to the southern portion and have him travel northward with the 
season, so that the following winter can be spent in the high and colder 
districts. 

It is of the utmost importance in a case of consumption to maintain 
the integrity of the digestive apparatus, and in selecting the place of 
abode the possibility of getting properly cooked food suitable to the in- 
dividual case is of importance. Further, what may be termed extraneous 
considerations often enter into the problem of choice of locality ; very 
frequently the opportunity for making a living, if not in the immediate 
present, in the near future, is of vital importance. In Texas, Southern 
California, Colorado, Wyoming, or other localities, ranch life or the cul- 
tivation of the soil in some way is open to many and gives work in the 
open air. In other cases the attractions of a cify like Denver are domi- 
nant. The altitude above the sea of San Antonio is 650 feet, of Santa 
Fe, which may be looked upon as the next important stopping-place, 
6840 feet, of Denver 5196 feet, of Colorado Springs 6000 feet. For a 
young man with pecuniary means we have no doubt that travel, hunt- 
ing, and tent life in this region afford the best obtainable chance of 
recovery. 

Professor C. B. Penrose, of the Medical Department of the Uni- 
versity of Pennsylvania, spent two years roaming over this arid district, 
and states as the result of his personal observation that a greater pro- 
portion of cases get well in New Mexico than in any other Western 
Territory or State. 

In the climatic treatment of phthisis it is important that the patient 
remain at the favored locality not for weeks or months, but for years. 



INFECTIOUS DISEASES. 



297 



The monotony of existence may sometimes advantageously be broken 
by travel in suitable localities. The question of the return of the ap- 
parently cured patient to his home is always a very serious one ; in the 
majority of cases permanent residence in a proper climate is essential. 

Second Indication. — Under the second indication — namely, the reduc- 
tion to the minimum of the local irritation and changes produced by 
the bacteria — may be considered the use of— first, certain pulmonic gym- 
nastics ; second, counter- irritation ; third, inhalations ; fourth, internal 
medicaments. 

In some cases of incipient phthisis the inhalation of compressed air 
in the so-called " pneumatic cabinet" gives good results, which are 
probably produced by a distention of the air -vesicles. It would seem 
that such inhalations are a very inferior substitute for high mountains, 
and should be used with great caution where there is a tendency to hem- 
orrhage. It is further probable that as much good can be obtained by 
means of a simple device consisting of a glass or other tube a quarter 
of an inch in diameter and six or seven inches long, with a pin-hole made 
at one side 5 the patient inspires through the tube, places the finger so 
as to close the aperture, and forces the air through the pin-hole with all 
the expiratory force at his command, repeating the act many times over. 
Similar results may be obtained simply by the habit of frequent forced 
inspiration and expiration. 

Counter-irritation is often of value in phthisis pulmonalis : it combats 
the local inflammation, but not the bacillus. In the earlier stages of 
the disease, when a small amount of tuberculosis in the apices produces 
much irritation with catarrhal pneumonic consolidation, the continuous 
application of croton oil over the upper chest may be very serviceable. 
Again, sinapisms or dry cups when there are congestive exacerbations, 
blisters in times of acute pleurisy, chloroform or other irritating embro- 
cations when there are neuralgic or muscular pains, and other similar 
remedies or measures, may be very useful if judiciously employed. Even 
wet cupping or other local blood-letting may sometimes be advantageous, 
although it has a tendency to lessen the strength of the patient. 

As inhalations and expectorant remedies are serviceable only by 
affecting the catarrh of phthisis, the remarks about the use of such 
remedies in the articles upon acute and chronic bronchitis are equally 
applicable to their employment in chronic pulmonic tuberculosis, and 
should be read in connection with the present subject. The checking 
or the supporting of the cough is governed by exactly the same prin- 
ciples in the two disorders. Morphine must, however, be used with 
especial care in phthisis, on account of its tendency to derange diges- 
tion and of the danger of the formation of the morphine habit ; more- 
over, there is often a necessity of husbanding this remedy as a means of 
euthanasia in the later stages of the disease. Sometimes sedative ex- 
pectorants are demanded by the patient to "loosen the phlegm;" it is 



298 



GENERAL DISEASES. 



necessary, however, to be guarded in their employment, lest the stomach 
be disturbed. No greater abomination exists than the multitudinous 
i i syrups' ' which formerly more than at present were employed in this 
disease, much to the detriment of the patient's digestion and well-being. 
Creosote and guaiacol are valuable remedies, especially applicable to cases 
with very free expectoration; the latter may be used hypodermically. 
Sulphuretted hydrogen, terebene, and the various expectorant volatile 
oils are all useful when there is much chronic catarrh or softening. In 
dry chronic cases with little catarrhal tendency the long-continued use 
of smaller doses of arsenic (one or two drops of Fowler's solution three 
times a day) may be very advantageous. 

Third Indication. — In any case of phthisis it is a matter of vital im- 
portance to study carefully the digestive organs, to adapt the food to the 
individual needs and condition of the patient, and to treat any symptoms 
of digestive failure very carefully as soon as they manifest themselves. A 
catarrhal state of the stomach and bowels must be at once met by appro- 
priate remedies. (See articles on Gastric and Intestinal Inflammations.) 
Especially in the advanced stages, not only comfort but also distinct ad- 
vantage is sometimes obtained by a system of forced feeding, consisting 
in a daily lavage of the stomach, followed by an injection into the stomach 
of quantities of nutritious, concentrated, easily digested foods. In some 
cases, in children more than in adults, free inunction with cod-liver oil 
seems to aid in the prevention of emaciation. 

When hcemoptysis occurs, the patient should be put to bed, and for- 
bidden to talk or to make any exertion whatever. Opium should be 
given in sufficient quantities to allay the nervous excitement and erethism 
which are almost invariably present, and to quiet cough if it should 
exist. At the time of the hemorrhage the taking of a large dessertspoon- 
ful or small tablespoonful of dry salt into the mouth is sometimes effec- 
tive : it evidently acts reflexly by irritating the mucous membranes of 
the mouth and pharynx. If the seat of the bleeding is apical, ice or 
other form of cold may be applied locally. If the case be severe, extract 
of ergot should be given hypodermically (fifteen grains with ten minims 
of glycerin and twenty minims of water), as well as by the stomach, if 
the latter be retentive. As ergot is an entirely safe remedy, it should be 
exhibited in large doses. If there be call for immediate haste, two to 
four fluidrachms of the fluid extract may be exhibited at once. After- 
wards the solid extract should be administered in capsules, as less apt to 
disturb the stomach ; from ten to twenty grains (equivalent to five times 
the amount of the fluid extract) may be given every half -hour to every 
two hours, according to the degree of emergency. Not more than an 
ounce of the ergot should be taken in the twenty- four hours. Other 
efficacious remedies are gallic acid, ten grains every one to four hours, 
and oil of erigeron, ten minims every one to four hours. Very frequently 
good results are obtained by alternating these remedies with each other 



INFECTIOUS DISEASES. 



299 



or with ergot. If there be excitement of the circulation and a full 
hounding pulse, aconite should be exhibited ; on the other hand, the use 
of stimulants, such as alcohol and digitalis, though in some cases impera- 
tive, must be very cautious, lest by increasing the force of the circulation 
they aggravate the hemorrhage. The older remedies, such as sulphuric 
acid, plumbic acetate, and oil of turpentine, are of very inferior rank to 
those above noted. 

" Night- sweats" are in no way peculiar to phthisis, and may occur in 
the daytime when the patient is awake. The antihidrotic drugs which 
are of value are atropine, extract of ergot, agaricin, gallic acid, and sul- 
phuric acid, named in the order of their power and general applica- 
bility. Of these, atropine has the disadvantage of producing great 
dryness of the throat and mouth and disturbance of the circulation if 
given in full dose. Unless there be a tendency to sweat during the day, 
it is best administered at bedtime, one-hundredth to one-sixtieth of a 
grain, often associated with some somnifacient ; if the tendency to sweat- 
ing be present at all times, one-hundred-and-twentieth of a grain may be 
given every eight hours. Extract of ergot is incapable of doing harm 
to the patient except by disturbing the digestion, and if administered in 
five- grain capsules it rarely does this. Ten grains may be given every 
two to four hours during the day, its action not being immediate like 
that of atropine, but rather continuous. Agaricin is often very effective 
given (three to five grains) in capsules every six hours ; it has some 
tendency to irritate the intestinal tract, but otherwise seems to act purely 
as an antihidrotic, exerting no perceptible influence upon the system. 
The action of the antihidrotic drugs may sometimes be aided by bathing 
the patient with alcohol at bedtime : some of the older authorities recom- 
mend the use of baths of decoction of oak bark, but we have had no 
experience with them. As after the sweat the bodily temperature is fre- 
quently subnormal, care should be taken in changing the underclothing 
to see that the patient is rapidly well dried, that the fresh underclothing 
is warm, and that the whole process is gone through as quickly as pos- 
sible, so as to avoid the danger of taking cold. 

The combating of the hectic fever in phthisis is often hopeless. The 
moderate use of antipyrin, phenacetin, and allied antipyretic drugs is 
sometimes advantageous. If, however, moderate doses fail, it is not right 
to employ larger amounts, because of their tendency to produce depress- 
ing sweats. Quinine is rarely effective. When the temperature rises 
above 103° F. no hesitancy should be felt in the use of cold sponging 
or of the tepid bath. 

The treatment of intestinal tuberculosis must have for its basis the gen- 
eral hygienic management and treatment already specified for chronic 
tuberculosis. Bismuth with carbolic acid, silver nitrate in capsules, 
creosote, chalk mixtures containing tannic acid, lead acetate, and other 
remedies suitable for the relief of intestinal catarrh and for the checking 



300 



GENERAL DISEASES. 



of diarrhoea when it becomes severe, must be used pro re nata. Opium 
is in many cases valuable. Externally, turpentine stupes, spice plasters, 
and all the milder counter-irritants may be employed upon occasion. 
Warm poultices or fomentations often give the most relief. 

The medical treatment of tubercular peritonitis consists, first, in the 
employment of such hygienic measures as have already been spoken of 
as useful in tuberculosis ; second, in the continuous use of mild counter- 
irritation, with careful feeding and the treatment of diarrhoea or consti- 
pation as may be needed. When diarrhoea exists, it may be considered 
to be the outcome of intestinal irritation or catarrh. Iodide of iron, 
especially in the case of children, is thought by some practitioners to 
be of great value. Most of the time the counter- irritation should be 
mild and continuous. Fomentations, poultices, and spice plasters may 
be used. Blisters are sometimes very effective in periods of exacer- 
bations. Tapping in ascitic cases has been long practised, often with 
advantage. Simple aspiration often does good. The most recent method 
of treatment is by laparotomy. 

Eoers has analyzed three hundred and fifty-eight cases of chronic 
peritonitis in which laparotomy was performed. There were only 
twenty deaths from the operation. Two hundred and fifty-three cases 
were reported as cured ; of these, fifty-three were still alive at the end 
of two years. It is not probable, however, that these cases were all 
tubercular, and there seems to be no light as to how far the residuum 
of fifty-three cases had originally been tubercular. Aldibert alleges 
thirty-nine cures in fifty cases in which tubercle was histologically or 
bacteriologically proved to be present. The accuracy of these figures 
can hardly go unchallenged, but the evidence is sufficient to warrant 
laparotomy in favorable cases of tubercular peritonitis. When there is 
tubercle elsewhere in the body, operative treatment is unjustifiable, and 
it is stated by Eichardson, of Boston, to be inadvisable when a localized 
peritoneal infection has produced fistula with general matting together 
of the intestinal viscera. The form of operation should vary with the 
form of the disease ; but for these surgical details the reader is referred 
to the paper by Eichardson in the fourth volume of Dennis's " System 
of Surgery.' 7 Tuberculosis of the kidneys, bladder, prostate gland, sem- 
inal vesicles, testes, mammary glands, lymph-glands, bones, and joints, all 
may be considered to be surgical disorders, especially to be treated by 
radical local measures when possible. The constitutional management 
of such cases is similar to that of chronic internal tuberculosis. 

In lupus or in scrofuloderma, when there is derangement of the general 
health, hygienic measures, with cod-liver oil and other nutritive stim- 
ulants, should be freely used. Especial value is attached by some to 
small doses of Lugol's solution (two drops ter die). Tuberculin has been 
largely used in lupus, but does not seem to have sustained the claim 
originally put forward for it. It would appear, however, that it does aid 



INFECTIOUS DISEASES. 301 

in removing the thickened and hardened tissues, and it may be employed 
from time to time, especially as a preliminary to severe local treatment. 
An effect similar to that of tuberculin has been alleged by H. von Hebra 
to be produced by thiosinamine. The local treatment is of especial value. 
The scraping off of the diseased tissues by means of the sharp dermal 
curette, as originally advised by Volkmami, may be done with local or 
general anaesthesia, the affcer-hemorrhage being controlled by pressure 
with absorbent cotton. After the scraping, dermatological authorities 
recommend various caustics : strong carbolic acid, fuming nitric acid, 
zinc chloride, chromic acid, pyrogallol (ten to fifty per cent, ointment), 
acid nitrate of mercury, and silver nitrate have each their supporters. 
Electrolysis has been used to a considerable extent with good results 
when the patches are small. Some specialists recommend that the local 
treatment be followed by tuberculin injections. 

LEPROSY. LEPRA. ELEPHANTIASIS GR^CORUM. 

Definition. — A chronic infectious disease, due to the invasion of the 
body by a specific organism, the bacillus leprae, which produces local- 
ized inflammatory disturbances in the skin, mucous membranes, nerves, 
and viscera, associated with disturbance of sensation, ulceration, and 
necrosis. 

Etiology. — Leprosy is a disease of wide distribution, sparing neither 
sex nor social condition. It prevails in early adult life, has never been 
found in the foetus, and is extremely rare in infants. The assumed consti- 
tutional nature of the disease and the etiological importance of inheritance, 
especially emphasized by Danielssen, have yielded, since the discovery 
announced by Hansen, in 1880, of the constant presence of a character- 
istic bacillus in most of the products of the affection, to the view that 
leprosy is both infectious and contagious and due to this bacillus. The 
contagious nature of the disease was strongly advocated by J. C. White 
in 1882. 

The bacillus of leprosy closely resembles in its various characteristics 
that of tuberculosis. Unlike the latter, it is not inoculable in the lower 
animals, and the statements of its having been successfully cultivated are 
still subject to criticism. The bacillus abounds in the diseased coriuni 
and subcutaneous tissue, and, according to the report of the India 
Leprosy Commission, is to be obtained in the fluid from blisters produced 
over the nodules, in the secretion from the ulcers, and in the saliva when 
the tongue and larynx are affected with the disease. It has rarely been 
found in the blood, and never in the urine. 

Leprosy arose in Central Asia in remote times, and, according to 
Hyde, followed the lines of travel to the shores of the Mediterranean, 
from which it was carried to Norway, Iceland, and Greenland in the 
north, and to Egypt and other parts of Africa in the south. In the 
mean time Central Europe became invaded. The disease also travelled 



302 



GENERAL DISEASES. 



east from its place of origin in Asia, and made its appearance in China, 
in Japan, and in the islands of the Pacific. In North America the valley 
of the St. Lawrence received the disease from Norway, Iceland, and 
Greenland, while, according to Graham, New Brunswick was invaded 
from Normandy. The States bordering upon the great lakes became 
infected largely from immigrating Scandinavians. The Northern Pacific 
coast received its supply of cases from China and the Sandwich Islands, 
while the southernmost States, Mexico, Central and South America, and 
the West India Islands, were invaded from Southern Europe. According 
to J. C. White, there are now two hundred and fifty thousand lepers in 
India, and it is estimated that there are at least two hundred in the 
United States. Hyde states that there have been recognized in this 
country, up to 1890, five hundred and sixty cases of leprosy. Of these, 
one hundred and fifty-eight were found in California, one hundred and 
twenty in Minnesota, and one hundred in New York. Graham learned 
that two hundred and fifty lepers have been cared for in New Brunswick 
since 1815, and that in 1894 there were about thirty cases. 

Morbid Anatomy. — The lesions distinctive of leprosy are the vari- 
ously distributed tubercles, nodules, and more diffused formations of 
granulation-tissue, which possess a considerable degree of permanency 
and therein differ from the granulation- tissue of tuberculosis and syph- 
ilis. The structure is chiefly composed of cells of various size, in par- 
ticular of large endothelioid cells, although leukocytes are also abundant. 
Within and between the larger cells the bacilli of leprosy are present in 
enormous numbers, thus strongly contrasting with the distribution in the 
tissues of the bacilli of tuberculosis. Ulcers and scars accompany the 
nodules, and the former may lead to a loss of fingers and toes. 

Symptomatology. — Two varieties of leprosy are usually recognized, 
the anaesthetic and the nodular, tubercular, or tuberous leprosy, although 
a combination of the two varieties may exist in rare cases, even from the 
beginning of the disease. 

The onset of leprosy is usually very gradual, and a period of years 
may intervene between exposure to the disease and the outbreak of the 
symptoms. Prodromal symptoms are usually present, but are of such a 
general character as to be of little significance. Weakness, dizziness, 
disturbed digestion, and slight fever are usually mentioned. 

In anaesthetic leprosy the first distinctive manifestations are spots, 
macules, which may be preceded by bullae, few or many, usually first 
appearing upon the face, hands, and feet, and afterwards elsewhere on 
the body. They are rounded or irregular in outline, for months remain 
stationary or recur from time to time, or gradually increase in size to 
that of the hand. They are of a red color, erythematous, at the outset, 
but tend to assume a brownish tint. The pigment later disappears, and 
the pale patches become anaesthetic. This insensibility may have existed 
from the outset, even in spots free from pigment, but in rare instances 



INFECTIOUS DISEASES. 



303 



is preceded by hyperesthesia or paresthesia of the tissue. There may 
be deep-seated pain as well, and the nerves, at first usually the ulnar 
and peroneal nerves, become thickened, indurated, and painful, though 
eventually benumbed from the leprous perineuritis in which the bacilli 
and granulation-tissue are present : hence anesthetic leprosy is regarded 
as a variety of peripheral neuritis. Contraction of the fingers and toes 
may follow, likewise trophic changes, evidenced by muscular atrophy, 
the formation of bulle, ulcers, and necrosis, and a loss of hair and nails 
and of fingers and toes. When the facial nerves are diseased, ulceration 
of the cornea may take place and be followed by perforation and blind- 
ness. The bacilli are not found in the secondary cutaneous lesions 
resulting from the neuritis, although they are present in the inflamed 
nerve-sheaths. 

Nodular or tubercular leprosy is characterized by the presence of nodules 
and of a diffused indurated swelling, developing at the outset especially 
on the face, hands, and feet. The nodules are somewhat sensitive to 
pressure, and vary in size from that of a pin's head to that of a filbert. 
They may develop from the macules or bulle previously mentioned, or 
may arise in an apparently normal part, and may increase in size and 
coalesce or become absorbed and recur. Eventually they are likely to 
soften and give rise to ulcers, superficial or deep, which may heal with 
deforming scars. When abundant in the skin of the face a leonine aspect 
is suggested, whence the term leontiasis, of which appearance there are 
other causes than leprosy. The mucous membrane of the mouth, pharynx, 
and larynx is a not infrequent seat of the leprous formations, and a hoarse 
or whispering voice, dyspnoea, and cough may be due to the laryngeal 
affection. From the conjunctival mucous membrane the nodules may 
extend into the cornea and be present in the iris, causing blindness. 
Nodules are also to be found in the lymphatic glands, testis, spleen, and 
liver. The lungs are almost invariably spared, but Bonome has recently 
found these organs affected. 

Diagnosis. — The diagnosis of leprosy in the early stages is exceed- 
ingly difficult. Essential for the recognition of the disease are the de- 
velopment of the characteristic anesthetic spots and the discovery of the 
bacilli in the nodules or secretion from the ulcer. Syphilis and cutaneous 
tuberculosis may be confounded with leprosy, but the macules of syphilis 
are more transitory and its nodules less permanent and contain no bacilli. 
The bacilli of cutaneous tuberculosis are less numerous in the lesions, 
especially in the cells, and are inoculable, thus differing from those of 
leprosy, which they so closely resemble. 

Prognosis. — The course of leprosy, especially of the anesthetic type, 
is exceedingly chronic, and the disease may last many years, a period of 
from four to twenty years having been assigned. The result is usually 
death from marasmus or an acute intercurrent affection, as pneumonia, or 
from a complicating tuberculosis or nephritis. Eecovery is possible in the 



304 



GENERAL DISEASES. 



case of the early discovery of limited lesions, although apparent cures 
are often followed by relapses or recurrences. Danielssen reports that 
he has observed ninety-two cures in forty-five years. 

Treatment. — The prophylaxis of leprosy is isolation of the leper. 
There is no specific treatment. Chaulmoogra and gurjun oil have been 
used both externally and internally with asserted beneficial results, but 
there is no reason for believing that they are capable of curing the 
disease. Treatment must be systemic and sustaining. 

SYPHILIS. 

Definition. — A chronic infectious and highly contagious disease, due 
to a specific virus of probably bacterial nature, producing a series of dis- 
turbances in more or less definite sequence in the skin and in various 
other parts of the body. 

Etiology. — Syphilis is wholly limited to man, and it has been found 
impossible to transmit the disease to the lower animals. The virus is 
transferred directly or indirectly from one person to another, the so-called 
acquired syphilis, or is communicated from parent to offspring, hereditary 
syphilis. A person once infected is usually rendered immune from a 
reinfection, although in rare instances a child who has inherited syphilis 
may again acquire this disease in adult life. Furthermore, Colles ob- 
served that the healthy mother of a child who had inherited syphilis 
from the father was protected from infection by the child, who, at the 
same time, is capable of infecting other healthy persons. The virus 
abounds in the secretion of the initial lesion and of the papules, espe- 
cially the moist papules in the secondary stage, and is usually consid- 
ered to be almost wholly absent from the latest products of the disease. 
Yon Zeissl suggests that the degree of contagiousness of the products of 
syphilis is dependent rather upon the time which has elapsed since infec- 
tion than upon the nature of the product. On the other hand, it is 
doubtful whether the virus is present in the pus not due to the lesions 
characteristic of syphilis. The blood in the earlier stages of syphilis 
may or may not contain the virus, and it is also probable that physio- 
logical secretions do not contain the specific virus unless the surface over 
which they flow bears a lesion capable of producing this agent. It is, 
however, generally agreed that the ovum becomes infected by the semen ; 
yet the latter secretion is generally thought to be incapable of directly 
infecting the mother, although it is considered possible that the latter 
may be infected from her syphilitic foetus. The bacterial nature of the 
virus has long been assumed from its power of indefinite reproduction, 
and Lustgarten has found bacilli which he regards as characteristic in 
the secretion from syphilitic ulcers and papules; they have also been 
found in other pathological products of syphilis, even in the gumma. 
They somewhat resemble the bacillus of tuberculosis and that of the pre- 
putial smegma. Other observers have reported the occurrence of various 



INFECTIOUS DISEASES. 



305 



forms of bacteria in this disease : so that the etiological importance of 
Lustgarten's bacilli and of the other bacteria is as yet undetermined. 

Acquired syphilis is to be found at all periods of life : even the 
new-born child may become inoculated during the process of parturi- 
tion. A local lesion of surface, although it is often so slight as not to be 
recognized, is necessary that the virus may be admitted to the body. 
The infection generally takes place during sexual intercourse, and the 
earliest manifestations are usually found upon or in the vicinity of the 
genitals, but in perverted intercourse may be seen elsewhere, especially >. 
upon the lips, tongue, and tonsils. Infection of the latter regions may 
arise without sexual perversion, since direct and indirect infection of the 
mouth may otherwise occur, the former by kissing, the latter by the use 
of infected articles, as pipes, drinking- cups, or other utensils used in 
common. The act of nursing may prove a source of infection from nurse 
to infant or from infant to nurse. The physician, surgeon, or nurse may 
be infected while caring for a syphilitic patient, and the syphilitic virus 
has been transmitted by the use of infected instruments by surgeon, den- 
tist, or barber. Both infants and operator have become infected during 
the act of ritual circumcision, and before the use of animal vaccine the 
syphilitic virus was repeatedly conveyed in vaccination. 

Morbid Anatomy. — The virus of syphilis produces a series of local 
inflammatory disturbances varying in degree from vascular injection and 
slight oedema to the formation of masses of dense fibrous tissue. Various 
terms are applied to these lesions, as sclerosis or induration, papule, 
tubercle, and gumma. The tissue of which they are composed is a 
granulation -tissue, which tends towards ulceration, absorption, or in- 
duration. Ulceration occurs when the inflammatory tissue lies near 
the cutaneous or the mucous surface, although epithelial desquamation 
without ulceration may take place, as in the case of cutaneous papules, 
and crusts of inspissated secretion and epidermis may adhere to the 
surface of healing ulcers. The lesion generally regarded as the charac- 
teristic of syphilis is the gumma or syphiloma, which may be of a size 
recognizable only with the microscope or may form a tumor as large as 
the fist. It occurs singly or in numbers, diffused or circumscribed, usu- 
ally in various parts of the body and near the surfaces, as well as in 
the interior, of organs and tissues, and is to be found, as a rule, during 
the later stages of syphilis. The older and larger gummata are com- 
posed of a series of opaque yellow masses of various size and irregu- 
lar outline, separated from a dense opaque white fibrous tissue by a 
translucent gray or grayish-red zone. The central cheesy mass is com- 
posed of fibrous tissue in which are necrotic cells and fat-granules ; the 
intermediary zone consists of abundant granulation-tissue, and the pe- 
ripheral fibrous tissue is cicatricial, containing few cells and abundant 
fibres. The blood-vessels of the gumma often sliow a cellular hyper- 
plasia of the intima with a corresponding diminution in calibre, fre- 

20 



306 GENERAL DISEASED 

quently resulting in the obliteration of the canal, and leukocytes may 
abound in the vicinity of the adventitia. The more voluminous the 
gelatinous granulation-tissue the more active the growth of the gumma. 
The absorption of the syphilitic fibrous tissue may take place with- 
out resulting deformity, while the course of a gummous inflammation 
tends to produce destruction in its vicinity, and the eventual arrest of 
the process leaves a cicatricial tissue producing more or less extensive 
deformity as well in bone as in the soft parts. 

The virus of syphilis is a frequent cause of chronic inflammation of 
the blood-vessels, especially the arteries, and, although the importance 
of syphilis in the etiology of chronic inflammation of the aorta in early 
life has long been recognized, Heubner first called attention to a similar 
process in the small arteries, especially in the brain. This obliterative 
endarteritis may be associated with a diffuse gummous inflammation, 
as in gummous leptomeningitis. Amyloid degeneration of the spleen, 
kidneys, stomach, and intestines finds in syphilis one of its chief causes. 

ACQUIRED SYPHILIS. 

Symptoms. — In the course of two or three weeks after inoculation, 
usually of the prepuce or vulva, although sometimes of the interior of 
the urethra, the initial or primary lesion of syphilis becomes manifest as a 
papule, an erosion, or an induration. Less often several of these lesions 
may be present, and a combination of erosion and induration known as 
the hard or Hunterian chancre is the usual manifestation. The essen- 
tial characteristic of the initial lesion is the induration or sclerosis, 
which is manifested as a rounded, flattened nodule, somewhat movable, 
embedded in the substance of the skin and projecting slightly above its 
surface. The sore or ulcer is represented by the smooth, shining, and 
moist surface over the centre of the nodule. This is not to be con- 
founded with the soft chancre, chancroid, or contagious venereal ulcer 
which follows inoculation in the course of four or five days, spreads 
rapidly, and usually suppurates within a fortnight, when healing takes 
place, resulting in the formation of a scar. This lesion is autoinoculable 
and sometimes contains the syphilitic contagium in addition to the chan- 
croidal virus. The ulcer of syphilis may become infected by various 
bacteria, and extensive suppuration, pseudo- membranous inflammation, 
erysipelas, or gangrene arise as complications without modifying the 
specific effects of the syphilitic virus. The ulceration usually lasts but 
a few days, but may persist for weeks when a complicating inflamma- 
tion of the surface exists. The induration continues for some time, usu- 
ally not disappearing until several weeks after the cutaneous symptoms 
of syphilis are manifest, and may be present after many years. In the 
course of a fortnight after the appearance of the induration the lymph- 
vessels become thickened and the inguinal lymph-glands markedly en- 
larged, hard, but without pain, forming the indolent bubo. This is to 



INFECTIOUS DISEASES. 



307 



be distinguished from the bubo of the soft chancre, which is of earlier 
occurrence, painful, of rapid increase in size, and manifesting a tendency 
to suppurate. 

The Secondary Stage. — Within from three to five weeks after the occur- 
rence of the sclerosis or induration, that is, within the course of two 
months after the infection, the secondary symptoms of syphilis indicative 
of a general infection become manifest, although exceptionally their de- 
velopment may take place earlier or later. Previous disease in an organ 
favors the subsequent localization of syphilis in it, and persons subject 
to naso-pharyngeal catarrh are prone to a syphilitic laryngitis, while 
syphilitic lesions of bones are of more frequent occurrence in parts 
especially exposed to injury. The lymph-glands in the various regions of 
the body become enlarged and indurated, and may remain thus altered 
for years even in the absence of other manifestations of the disease, and 
the periosteum, bones, and viscera may become diseased. These sec- 
ondary symptoms in rare instances occur as a single attack lasting a few 
months, or progress with such rapidity and severity as to have received 
the designation of malignant syphilis. Usually, however, recurrent out- 
breaks take place, separated by an interval of months, in which the dis- 
ease is regarded as latent, and the period during which recurrences are 
probable generally extends over a year or two. 

Among the earliest secondary symptoms is the eruption or rash ap- 
pearing upon the skin and the visible mucous membranes, to which the 
term syphilide is applied. The eruption is free from itching, and may 
be preceded or accompanied by a fever, represented by disturbance of 
digestion, muscular pains, headache, and prostration, and by an elevated 
temperature and quickened pulse. Albuminuria and enlargement of the 
spleen are associated. This symptomatic fever may also accompany re- 
current attacks. The rash or eruption occurs as macules, papules, and 
pustules, and an important characteristic is the simultaneous occurrence 
of the several varieties, known as polymorphism. The rash is irregu- 
larly rounded, sharply defined, deeply pigmented, often copper-colored, 
and abounds in certain regions of the body, especially on the forehead, 
near the edge of the scalp, in the vicinity of the genitals, on the palms 
of the hands, and on the soles of the feet. The macular syphilide, syphi- 
litic erythema, or roseola, appears especially upon the trunk as reddish- 
brown spots, fading somewhat on pressure, and becoming more conspic- 
uous on the application of heat or cold to the skin. This rash lasts 
several days, fades during a severe intercurrent febrile attack, and 
frequently recurs during the latter part of the secondary period. Its 
presence in the nose is associated with coryza, and when occurring in 
the throat it gives rise to the syphilitic sore throat. 

The papular syphilide may accompany or follow the macular rash, and 
is either sharply defined or has an erythematous base. The papules often 
occur in large numbers, widely distributed over the body, and present a 



308 



GENERAL DISEASES. 



variety of appearances according to the degree of development and the 
secondary changes. The miliary or syphilitic papule, syphilitic lichen, 
is distinguished especially by its size from the more common large papu- 
lar syphilide. The former is about as large as a pin's head, and is 
found in the vicinity of the hair- follicles, especially in debilitated per- 
sons, and indicates a severe type of disease. The large papular syphi- 
lide occurs singly or in clusters, and persists for weeks, when the epi- 
dermis desquamates from the surface and absorption gradually and 
completely takes place. The presence of these papules at the angles of 
the mouth and in the interdigital folds of the skin is frequently asso- 
ciated with cracks, which readily bleed. In like manner when nu- 
merous upon the palms and soles the thickened skin becomes fissured 
and painful, such localization receiving the term syphilitic psoriasis. 
When the papules are present in moist places exposed to friction, as 
the region of the anus and genitals, the axillae, between the fingers and 
toes, below the breast, the folds of the navel, the mouth and pharynx, 
the surface of the papules becomes macerated, perhaps ulcerated, and 
frequently bleeds. They then receive the term mucous patches, plaques 
muqueuses, or broad condylomata lesions, which are among the most 
contagious manifestations of syphilis. They frequently occur in num- 
bers, and when clustered, fissured, and surrounded by inflamed skin, 
interfere with the function of the part by causing pain, hence pro- 
ducing difficulty in swallowing, nursing, and defecation. When present 
on the tongue, soft palate, uvula, tonsils, and pharynx, they are likely 
to form ulcers. Papules becoming mucous patches and associated with 
catarrh also occur in the larynx. 

The term pustular syphilide is applied when the papules suppurate, 
a condition which is present in the severer forms of syphilis. According 
to the size and secondary changes in the suppurating papules are sug- 
gested the resemblances to acne, ecthyma, pemphigus, and variola. Acne 
is simulated when the pustules are in the vicinity of the hair-follicles, 
and therefore when they abound in the hairy parts of the body. Pus- 
tules enlarged to the size of peas and surrounded by a large dark- red 
infiltrated circle resemble ecthyma. The suggestion of variola is pre- 
sented by umbilicated crusts formed by desiccation, while in syphilitic 
pemphigus the pustules become confluent and suggest a suppurating 
blister. 

After the disappearance of the secondary manifestations of syphilis, 
especially in women, white patches, leukoderma, with an increased quan- 
tity of pigment in the vicinity, often occur upon the neck and elsewhere 
on the body. 

General loss of hair, syphilitic alopecia, accompanies the outbreak of 
the rash, especially three or four months after the infection, the growth 
of hair being subsequently restored. The eruption of the papules or 
pustules in the bed or at the side of the nail, syphilitic onychia and 



INFECTIOUS DISEASES. 



309 



paronychia, occurs soon after the loss of hair, and causes destruction or 
deformity of the nail. 

Among the secondary manifestations of syphilis is periostitis, indi- 
cated by severe pain called osteocopic, especially marked at night, and 
accompanied by localized swelling. The usual result of the inflamma- 
tion is a thickening and induration of the bone from both a periosteal 
and a central growth. When the periosteal growth is circumscribed it 
is called a node or exostosis, and is found especially upon the tibiae, the 
clavicles, and the outer surface of the cranium. More rarely a perios- 
titis is purulent, producing a gelatinous pus, which is either evacuated 
or absorbed ; in the former case a superficial caries is probable, in the 
latter a bone-scar results. 

Syphilis is the cause of nearly one-half of all cases of iritis, although 
iritis occurs in only about five per cent, of cases of syphilis. This affec- 
tion usually accompanies the first outbreak or first recurrence of the rash, 
and therefore appears within the first six months of the infection. The 
milder forms are to be recognized as productive of little functional dis- 
turbance, but are associated with congestion at the edge of the cornea 
and discoloration of the iris. When papules are present in the iris there 
is severe pain referred to the eyes, aggravated at night, with intoler- 
ance of light. Choroiditis is a secondary symptom which sometimes 
accompanies iritis, but may occur independently of it. 

The course of pregnancy is unfavorably affected by syphilis, since 
abortion or miscarriage is usually occasioned during the earlier manifes- 
tations of the disease : the habit of aborting should therefore suggest 
syphilis as a cause. Pregnancy also tends to prolong the duration of the 
symptoms of syphilis, although in the later stages of syphilis impreg- 
nation may be impossible. 

The Tertiary Stage. — The later symptoms of syphilis are manifested 
by the presence of the gumma or syphiloma and by disease of the bone 
and viscera. Such manifestations usually begin several years after the 
infection, and are generally separated from the secondary symptoms by 
a period of latency, although in rare instances of severe syphilis the gum- 
mata may appear within six months of infection and be associated with 
the secondary lesions. The small gummata in the skin produce the 
tubercular syphilide. This is manifested by the presence of nodules, 
either few or many, sharply defined, brownish-red, resistant, and slightly 
projecting above the surface, of the size of a pea or bean, and starting 
from the deeper layers of the skin. They may be absorbed, but usually 
as the surface is approached break down and form sharply defined, 
rounded, and deep ulcers, which increase in size by a similar change 
in other nodules at the periphery. Their course is chronic, and they 
may heal at one part and progress at another, thus at times causing ex- 
tensive cicatrices resembling those produced by burns. They also tend 
to recur. These ulcers are sometimes surmounted by crusts of inspissated 



310 



GENERAL DISEASES. 



secretion of considerable size with edges lamellated like those of an oyster- 
shell, when the term rupia is applied to them. 

The larger gummata form tnmors of the skin and mucous membranes, 
muscles, bones, and viscera. The gumma of the skin, as distinguished 
from the tubercular syphilide, begins in the subcutaneous tissue, and 
gradually increases in size, perhaps to that of a walnut. It eventually 
adheres to the skin, and becomes either absorbed or necrotic, in the 
latter case ending in an ulcer and a scar, as does the syphilitic tubercle. 

Gummata of the mucous membranes occur as small nodules, gradually 
increasing in size, and resulting in indurated ulcers which spread lat- 
erally and in depth, causing extensive destruction ending in deforming 
scars or in perforation of bones or cartilage covered with mucous mem- 
brane. Such gummata are of more frequent occurrence in the mouth, 
pharynx, and rectum, but are rare in the stomach and intestine. The 
nasal septum may be perforated and the root of the nose sink in, and 
portions of the hard and the soft palate and of the uvula may be 
destroyed. The soft palate is at times united to the posterior pharyn- 
geal wall, and forms an unyielding diaphragm across the naso- pharynx, 
through which sometimes a very minute opening is left. The exten- 
sive cicatrization of the tongue and pharynx and the perforation of the 
palate interfere with speech and deglutition, and even with respiration. 
Gummata of the rectum during the stage of ulceration cause painful 
defecation, while in the stage of cicatrization intestinal obstruction may 
result. The leukoplaques or milk spots often found in the mouths of 
syphilitics during the later stages have no necessary connection with 
this disease, as they occur in many persons free from venereal taint. 

The bones are a favorite seat of gummata, which may develop from 
the periosteum as a gummous periostitis or from the bone-marrow as a 
gummous osteomyelitis. The superficial gummata are hard and pain- 
ful at first, then become soffc and elastic, and occasion the progressive 
destruction of the bone and the formation of sequestra. The overlying 
skin becomes ulcerated and perforated, and the carious bone is exposed. 
Both flat and long bones may become thus diseased, the cranial bones 
in particular being frequently affected, and the resulting gummata may 
form tumors of the inner and outer surfaces of the bone, leading to per- 
foration of the skull and exposure of the dura mater. The projection 
of gummata from the bodies of the vertebrae may compress the spinal 
cord, while absorption of the central gummata of long bones canses one 
variety of the spina ventosa found in macerated bone. Gummata also 
form in the joints in both the synovial membrane and the ligaments, 
while the adjoining tendons and the bursse, especially the tendo Achillis, 
are not infrequent seats of the gumma. In dactylitis syphilitica there is 
a chronic inflammation of the fingers and toes, due to a diffuse gum- 
mous affection of the subcutaneous tissue, which eventually reaches the 
periosteum and involves the ligaments. 



INFECTIOUS DISEASES. 



311 



G-uinmata occur in the muscles, especially in those of the upper part 
of the body, as circumscribed, somewhat movable indurations, and usually 
disappear by absorption. The occurrence of a chronic fibrous myositis 
independently of the formation of gummata as a late result of syphilis 
is considered probable by certain writers. 

Visceral Syphilis. — The lesions of syphilis are often found in the in- 
ternal organs. Syphilis of the brain and cord is considered in detail in the 
section on Diseases of the Nervous System (see pages 528, 592, 618). The 
occurrence of gummata of the stomach and intestine has been referred to. 

Numerous observations have been made of gummata of the lungs, 
which have been described as being as large as an egg, as few or several, as 
occurring at any part of the lung, and as closely simulating in appearance 
cheesy tubercles. They are a late manifestation of syphilis, and are produc- 
tive of no disturbance to the function of the lungs. In the light of our 
present knowledge, the occurrence of pulmonary symptoms in acquired 
syphilis, especially when associated with signs of solidification of the lung, 
is to be regarded rather as a complication than as a result of this disease. 

Syphilis of the heart occurs in the form of gummata or of a diffuse 
fibrous inflammation, or of both combined. The gumma is to be found 
within the myocardium, either alone or with other gummata, and may be 
as large as an apricot. The diffused formation of fibrous tissue may take 
place in the pericardium, myocardium, or endocardium, in the vicinity 
of the valves or remote from them. Mracek has recently collected sixty- 
one cases regarded as of unquestionable cardiac syphilis. The conspicu- 
ous symptoms were those attributable to muscular insufficiency, and were 
characterized by palpitation, a sense of oppression, pain, and dyspnoea, 
even severe angina pectoris. Semmola calls especial attention to extreme 
irregularity in the action of the heart. In one-third of the cases collected 
by Mracek death occurred suddenly, either taking place without warn- 
ing or being immediately preceded by coma or epileptiform convulsions. 

Heubner has called attention to the importance of syphilis in the 
etiology of endarteritis, especially of the smaller arteries of the brain. 
Both a periarteritis and an endarteritis may occur in this organ as late 
lesions of syphilis even if the cerebral gumma or a gummous inflamma- 
tion of the meninges is absent, and produce various disturbances depend- 
ent upon the seat and distribution of the arteries. The affection of the 
blood-vessels is especially pronounced in those cases of cerebral syphilis 
in which the symptoms resemble those of general paralysis. It has long 
been recognized that chronic thickening of the aortic intima previous 
to the age of forty is principally due to syphilis, and many authors con- 
sider that a similar alteration of the arteries elsewhere may be due to 
the same cause : hence this disease is regarded as of importance in the 
etiology of aneurisms and disease of the heart and kidneys in which 
chronic endarteritis is a conspicuous feature. Further attention is given 
to this subject in the consideration of the affections of the arteries. 



312 



GENERAL DISEASES. 



Syphilis of the liver is also manifested by the occurrence of gummata 
and a diffuse fibrous inflammation. The gummata occur particularly in 
the vicinity of the suspensory ligament, often in groups, and are to be 
found isolated in other parts of the liver, both near the surface and within 
the substance of the organ. As a result of the absorption of the gummata 
the liver is divided by the contraction of the surrounding cicatricial tis- 
sue into irregular lobulations, which are often associated with a fibrous 
perihepatitis, and the lobulated liver is as suggestive of syphilis as the 
gumma is pathognomonic of this disease. Syphilis of the liver is not 
characterized by other symptoms than those dependent upon obstruction 
to the portal circulation, which is usually moderate in degree. Gummata 
are also to be found in the pancreas and the spleen, and rarely in the 
kidneys and the suprarenal capsules. 

Syphilis of the testis is an important affection as frequently leading 
to the recognition of the cause of obscure conditions due to visceral 
syphilis. There are two products, one an interstitial orchitis, the other 
a gumma, although both may be associated. In interstitial orchitis there 
is fibrous thickening of the tunica albuginea and the septula of the testis, 
and, in consequence, on section of the gland an arborescent appearance 
is presented suggesting that of a deer- horn. The testicle becomes atro- 
phied in consequence of the contraction of fibrous tissue, and a symmetrical 
or irregular shrinkage results. The gumma is indicated by an enlarge- 
ment of the testicle, due to the presence of one or several gummata, which 
increase in size, tending to produce a symmetrical enlargement, syphilitic 
sarcocele, or syphilitic testicle, with increasing destruction of the tubules, 
and the tunica vaginalis becomes obliterated, from an associated perior- 
chitis. Both interstitial orchitis and the gumma may be found in one 
or both testes, progressing slowly, and usually unaccompanied by other 
symptoms than those caused by the size and weight of the gummous 
testicle. The gummous differs from the tuberculous orchitis in the usual 
limitation of the process to the body of the testicle, and in the cus- 
tomary freedom from disease of the epididymis, vas deferens, seminal 
vesicle, and prostate. It differs from malignant tumors of the testicle 
in slowness of growth and freedom from pain, and from both malignant 
and tuberculous testes in showing no tendency to ulceration or to the 
formation of fungous excrescences. Despite these differences, the syphi- 
litic testicle has often been removed with the diagnosis of sarcoma. Ab- 
sorption of the gumma may take place with induration, while softening 
or suppuration rarely occurs. Gummata and interstitial inflammation 
may occur in the ovaries and in the mammary gland. 

HEREDITARY SYPHILIS. 

Hereditary syphilis is derived from either father or mother or from 
both parents, the semen or ovum being capable of conveying the dis- 
ease ; and it has been observed that one of a pair of twins may inherit 



INFECTIOUS DISEASES. 



313 



syphilis while the other remains exempt. A distinction may be drawn 
between hereditary syphilis and congenital syphilis, the former repre- 
senting an infection of the semen or ovum, while in congenital syphilis 
both parents may be free from the disease at the time of conception, yet 
the mother be subsequently infected, perhaps by a third person, and in- 
fection of the foetus result, this event being the more probable the younger 
the foetus. This method of infection has been designated intra-uterine, 
although Kassowitz concluded that the syj)hilitic virus does not pass 
through the vascular walls dividing the foetal from the maternal blood. 
As a rule, the syphilitic father infects the wife and has syphilitic off- 
spring, but a syphilitic father may impregnate a healthy mother and may 
or may not beget a syphilitic child. A healthy father may impregnate 
a syphilitic mother and a like result follow. The likelihood of the syph- 
ilitic father or mother begetting syphilitic offspring apparently depends 
upon the stage of the disease in the parent at the time of conception. 
If in either the earlier manifestations of syphilis are present, the child is 
usually syphilitic. If both parents show the earlier manifestations of 
syphilis, the child is sure to be syphilitic. If, on the contrary, syphilis is 
latent in the parents at the time of conception, the offspring may or may 
not be syphilitic. If there have been no symptoms of syphilis for sev- 
eral years in either parent, or if only tertiary manifestations be present, 
the children are likely to be free from syphilis. The limit of time be- 
tween the infection of the parent and the possibility of transmitting 
syphilis has been somewhat arbitrarily fixed at from four to six years, 
although cases are reported in which after many years from infection 
syphilis has been transmitted. It is generally agreed that the tendency 
to transmit syphilis to the offspring is diminished by antisyphilitic treat- 
ment. 

Morbid Anatomy. — In hereditary syphilis, in addition to such cir- 
cumscribed and diffuse formations of fibrous tissue as occur in acquired 
syphilis, there is to be found the typical lesion discovered by Wegner near 
the epiphyses of the long bones and known as syphilitic osteochondritis. 
It is characterized by an excessive width of the zone of ossification, the 
edge of which is jagged. The lime salts are irregularly deposited in it, 
and an extreme brittleness results, in consequence of which the epiphyses 
may be separated from the shaft. Especial importance is to be attached 
to the alterations found in the lung, since they frequently prove the 
immediate cause of death. The white hepatization first described by 
Virchow, in which the lungs are distended, non-crepitant, of a grayish- 
white color, and the alveoli filled with epithelium in a state of fatty 
degeneration, is found in the still-born or in those dying soon after birth. 
Heller has recently described the frequent occurrence of a fibrous pneu- 
monia due to inherited syphilis and more or less extensively distributed 
throughout the lungs. Both the cellular infiltration and the fibrous 
thickening of the interstitial tissue cause a narrowing of the alveoli, 



314 



GENERAL DISEASES. 



while the lungs are large, red, and dense. The infected portions of the 
lung are often emphysematous. This fibrous pneumonia occurring in 
families in which the older children were born prematurely or died of 
syphilis during or after birth may or may not be combined with other 
manifestations of syphilis. Gummata are stated to be present in the lungs 
in one-fourth of the cases of inherited syphilis. Among the visceral 
lesions of clinical importance to be met with in hereditary syphilis are 
enlargement of the liver, in which miliary gummata may occur, en- 
largement of the spleen, often forming a palpable tumor, and fibrous in- 
duration of the pancreas. Combined fibrous thickenings and gummata 
may be found in the several viscera, though more rarely than in acquired 
syphilis. 

Symptoms. — The more recent the infection of the parent at the time of 
conception, the earlier after birth do the symptoms of hereditary syphilis 
make their appearance. They are usually more severe if the syphilis is 
inherited from the mother, while the older children of syphilitic parents 
commonly suffer more seriously than the younger from the manifestations 
of the disease. As has already been stated, abortion or miscarriage is 
the frequent outcome of impregnation soon following infection. In sub- 
sequent pregnancies the children may be still-born, or may live for a few 
minutes after birth, in which case white hepatization of the lungs is often 
found and ecchymoses are frequent : the so-called hemorrhagic syphilis 
of the new-born may find an explanation in this affection of the lungs. 
In the children of later pregnancies the symptoms of syphilis become 
manifest in the course of days, weeks, or months after delivery, according 
to the duration and severity of the symptoms in the parent. The longer 
the period between birth and the development of the symptoms of syphilis 
the more possible is intra-uterine infection as a cause, and a knowledge of 
the previous history of the parents becomes important when answering 
the question whether the syphilitic symptoms in the child at the end of 
six weeks after delivery are due to inherited syphilis or to infection, either 
intra-uterine or during birth. 

The infants of enfeebled vitality from inherited syphilis are small and 
emaciated, showing both the cutaneous and the visceral lesions of syph- 
ilis. Coryza and a feeble, hoarse cry are often present. Pemphigus is 
especially frequent, either at birth or within a day or two afterwards, as 
purulent blisters upon the hands and feet ; and this syphilide is of grave 
import. The characteristic changes of the epiphyseal cartilage are to be 
found, and death usually occurs, often being the result of pulmonary 
syphilis or of broncho-pneumonia. Other children may appear well 
nourished at the time of birth, but in the course of a few weeks, usu- 
ally not later than three months, according to the stage of syphilis in 
the parent, the symptoms of hereditary syphilis appear, generally con- 
fined to the skin and the mucous membranes. Macules, often combined 
with papules, abound. The papules near the mouth, anus, and genitals 



INFECTIOUS DISEASES. 



315 



rapidly become mucous patches, while those upon the palms and soles tend 
to assume the characteristics of psoriasis. Pustules rapidly develop and 
tend to coalesce, especially upon the hands and feet, producing pemphigus. 
Snuffles also appear, and may even precede the rash, and the skin in the 
vicinity of the nostrils becomes macerated and ulcerated, while crusts 
form and interfere with respiration, especially when nursing. Cutaneous 
ulcers and gummata are rare early manifestations of inherited syphilis, 
although the ulcerated gumma of the nasal septum leads to the depression 
of the root of the nose, with its suggestive deformity. The nutrition of 
the child becomes impaired, the infant is wrinkled, anaemic, and fretful, 
and its death is likely to take place within a few months. 

The child may recover from the immediate manifestations of heredi- 
tary syphilis, but its development is usually stunted, rickets is frequent, 
and chronic osteitis may cause sclerosis of the bones. As the age of 
puberty is reached, a fresh outbreak of the disease may arise, and gummata 
and ulcers frequently appear. Hutchinson regards as indicative of hered- 
itary syphilis the combination of keratitis, producing more or less per- 
manent opacity of the cornea, labyrinthine disease, causing deafness, and 
a crescentic notching of the upper middle incisor teeth, which are also 
farther apart at the base than at the cutting edge. Such alterations may 
be due also to other conditions seriously modifying nutrition, and there- 
fore are not absolutely characteristic of inherited syphilis. 

Diagnosis. — The diagnosis of syphilis is not to be made until indura- 
tion in the region of the primary lesion and in the neighboring lymph- 
glands has taken place. The recurrent and polymorphic nature of the 
eruption and its association with indurated glands makes the diagnosis 
during the secondary symptoms relatively easy, despite the frequent 
assertion of no known exposure. In the latest stage of cutaneous syphilis 
the obstinate ulcerations of gummata are to be discriminated from lupus, 
that is, cutaneous tuberculosis, which they most closely simulate. The 
gummata are vascular, painful, and rapidly form deep, crater-like ulcers, 
which are benefited by antisyphilitic treatment and heal with the for- 
mation of depressed scars. Cutaneous tuberculosis, on the other hand, 
usually begins early in life, progresses slowly, and gives but little pain. 
There is extensive cheesy degeneration ; the ulcers are less sharply de- 
fined, are not benefited by antisyphilitic treatment, and, when healed, are 
replaced by superficial scars. The diagnosis of cutaneous tuberculosis is 
to be made by the histological examination, the discovery of the character- 
istic bacilli, or the occurrence of positive results from the inoculation of 
portions of the growth. Visceral syphilis produces disturbances in func- 
tion of various organs in no way differing from those due to other causes. 
The history of the patient may aid in the differential diagnosis, and the 
physical examination may show the induration left from a primary lesion, 
general enlargement of the lymphatic glands, deep and deforming cica- 
trices of the skin, pharynx, or rectum, tibial nodes, or a syphilitic testicle. 



316 



GENERAL DISEASES. 



Visceral syphilis may yet exist, although the physical examination of the 
surface of the body gives no aid in recognizing the cause of the visceral 
lesions. The diagnosis of the especial lesion of the organ concerned and 
the means of forming an opinion as to the cause of the lesion are especially 
considered in the description of the diseases of the various organs. 

Prognosis.— The prognosis of acquired syphilis is never to he defi- 
nitely forecast. Although spontaneous cures may occur at any stage in 
its progress, various treatments prove effectual, and the so-called specific 
treatment often produce almost immediate benefit, there are cases obsti- 
nate to all forms of treatment, temporary benefit may be followed by 
a renewed outbreak, and even without external manifestations visceral 
lesions may slowly progress. There is no absolute test of the time when 
recovery from syphilis has taken place. Experienced authorities agree 
that a period of two to four years must elapse before the probability of 
recovery is assumed. In general, syphilis pursues a milder course in 
strong vigorous persons of cleanly habits and in favorable surroundings, 
while the progress is slow and severe in persons debilitated by insanitary 
surroundings or by tuberculosis, scrofula, malaria, or alcoholism. The 
idiosyncrasy of the patient is also of importance, perhaps, to be explained 
by the relative immunization of certain individuals in virtue of syphilis 
in a near ancestor. When death results, it is due either to an exten- 
sive invasion of the brain or to the localization of the disease in a part 
especially necessary for the maintenance of life, as important cerebral 
centres, the heart, or the lungs, or to an extensive destruction of an im- 
portant organ, like the liver, or to a limited but prohibitory interference 
with the function of the alimentary canal. Syphilis also acts as one of 
the conspicuous causes of general amyloid degeneration, the presence of 
which is necessarily fatal. 

The prognosis of hereditary syphilis is extremely grave, since, accord- 
ing to Kassowitz, one-third of those diseased die in the first six months 
of life. The prognosis is the more favorable the later after birth the 
manifestations appear. 

Prophylaxis. — Although in recorded cases syphilis has been con- 
tracted from drinking out of cups attached to public fountains, from 
accidental contact with individuals infected with the poison, and in 
numerous other strange methods, even at the communion-table, such 
accidents are so rare and unforeseeable that they must be considered 
among the calamities of life against which no prevision can protect. 
Accidental infection of the practitioner of medicine is unfortunately not 
infrequent, — liable to occur to any gynaecologist, obstetrician, or surgeon. 
In the vast majority of cases, however, syphilis is produced by impure 
coitus, and is to be avoided by a moral life. 

Attempts have been made to prevent the development of syphilis by 
the regulation of prostitution, a practice which, indeed, prevails in a 
large part of Europe. Without occupying space with any detailed dis- 



INFECTIOUS DISEASES. 



317 



cussion of this matter, we desire to express our conviction that such regu- 
lation is, at least so far as concerns the United States of America? not a 
measure to be favored. We have reached this conclusion not through 
any moral or philanthropic reasoning, nor have we any sentiment con- 
cerning the matter. If syphilis could be banished, or even seriously 
diminished, by licensing houses of prostitution, we believe that it would 
be the duty of government to disregard the feelings and rights of indi- 
viduals as ruthlessly as it disregards the right of animals to live when it 
sets a bounty upon the heads of wolves. We believe, however, that no 
measures that can be taken would be of any value. It is notorious that 
although police espionage and bureaucratic government have reached in 
Europe their seemingly most perfect development, and although such 
government has strained itself to the utmost to protect its citizens from 
syphilis, yet syphilis is most rife in those countries in which the gov- 
ernment most assiduously attempts to protect its male citizens from 
the consequences of impure life. In the United States, where respect 
for the rights of the individual is carried to an extreme, where the 
government itself has the looseness and inefficiency which seem to be 
the inevitable outcome of democracy, we believe that any attempt at 
such regulation of prostitution would rather increase than diminish the 
spread of the disease ; because it would, in a measure, increase sexual 
impurity by taking away the fear of consequences, which undoubtedly is 
a check upon many, and because by the sense of confidence begotten it 
would diminish the watchfulness of the individual to protect himself 
from the results of his own acts. 

The question of marriage is continually referred to the practitioner by 
persons suffering from syphilis. The statements of syphilographers as 
to the time when marriage may be contracted with a fair probability of 
health to the woman and to the offspring vary. In our opinion four years 
is the least period which should be allowed to elapse. The number of 
women whose lives have been wrecked by marriage with syphilitics is 
appalling. The rule should be absolute that at least two years of con- 
tinuous treatment and two years of interrupted treatment should pass 
by before marriage is contracted. Syphilitic lesions which occur after 
this date are generally believed to be non-contagious and not inheritable. 

Treatment. — There are only two drugs which are of value in the 
treatment of syphilis, — namely, mercury and potassium iodide. Of 
these mercury is especially adapted to the early stages of the disease, 
iodide to the later. The first question which the physician has to 
answer is when to begin specific treatment. There are two different ideas 
held concerning this subject by syphilographers : according to one teach- 
ing, specific medication should be begun just so soon as the diagnosis is 
made out ; according to the other, it should not be entered upon until 
distinct secondary manifestations appear. According to our belief, the 
first of these teachings is correct ; but, on the other hand, mercurials 



318 



GENERAL DISEASES. 



should not be given until the diagnosis is established, as it is a matter of 
vital importance for the individual to know whether he has or has not 
syphilis ; whereas if mercurials be given before this knowledge is attained 
certainty may be impossible. We believe specific treatment should be 
commenced as soon as the diagnosis is made, for various reasons, as im- 
portant among which may be mentioned the possibilities of permanent 
local injuries by the specific lesions and the great danger of the accidental 
infection of other individuals through the presence of the primary sore. 
Moreover, although in some parts of the world the public knowledge that 
a man has had syphilis does not sensibly injure his prospects in life, it is 
not so in the United States. We do not believe that any advantage is 
gained by waiting. The talk of certain prominent syphilographers about 
the disease getting "ripe" seems to us a remnant of mediaeval fetichism. 

Mercury may be administered by the mouth, by inunction, or by 
hypodermic medication. In the great majority of cases, especially in 
the beginning of the disease, administration by the mouth is preferred, 
inunctions being to many unpleasant and often involving the risk of 
discovery ; hypodermic injections are also more or less unpleasant and 
require some skill in their administration. Both inunctions and hypo- 
dermic medication have the great advantage of being less liable to disturb 
the digestion and produce diarrhoea, and on occasion must be used. 

Syphilographers vary greatly in their recommendation of individual 
preparations of mercury : some prefer mercury with chalk or gray pow- 
der, others adhere to blue pill or to calomel, whilst still others affect 
the red or the green iodide of mercury. It is probable that one of these 
preparations is as effective as the other, provided it be given in the 
proportionate dose, although clinical experience shows that sometimes 
one, sometimes another, suits better the individual case. 

Again, two methods of using the mercury exist : one is to make a 
series of acute attacks, so to speak, of mercurialism ; the other is to 
maintain a steady mild influence. It is very doubtful whether one of 
these plans has any distinct advantage over the other. We have pre- 
ferred to use the milder method, to give the mercurial steadily in such 
dose as shall keep the condition just below that of ptyalism. When the 
syphilitic processes are active, and especially when they involve a vital 
organ, mild ptyalism should be produced if it be possible. 

The length of time over which mercurialization is to be carried 
should, in our opinion, be about two years. The mercurial course should 
always be followed by one of potassium iodide, which should be kept 
up for many months or a year, the drug being given in such dose as not 
to disturb the digestion or produce any systemic effect. The object of 
this procedure is twofold : the prolonged exhibition of mercurials leads 
to the deposition of mercury in the tissues, whilst the iodide restores this 
mercury to a soluble salt, with a consequent reabsorption into the blood 
and elimination. In the second place, the iodide is a very useful remedy 



INFECTIOUS DISEASES. 



319 



in the relief of remaining processes of the specific disease : it should be 
given in increasing doses until evidences of iodism are induced, and then 
in half or three-quarter doses continuously for one year. 

As a rule, the mercurials and potassium iodide are much better borne 
by syphilitics than by normal individuals, so that the failure of one of 
these drugs given in large doses to produce systemic reaction is presump- 
tive, though not positive, evidence of the existence of syphilis, provided 
the immunity has not been obtained by the gradual use of the remedy. 
Nevertheless, there are syphilitic persons who will not tolerate mercury, 
or in whom the iodides in minute doses produce at once constitutional 
symptoms. In such persons it will usually be found that the small dose 
of the mercurial or of the iodide accomplishes, so far as the disease is 
concerned, the same result as in the ordinary individual is produced by 
the larger dose. The presence of the idiosyncrasy is therefore not an 
indication for the withdrawal of the drug, but for the reduction of the 
dose. In giving potassium iodide it is often essential that doses as large 
as can be borne be administered. In a doubtful case ten grains three 
times a day may be first given ; a few days later, twenty grains ; if this 
be tolerated, forty grains may be administered at once ; and if this pro- 
duce no iodism, three drachms a day may be given in dilute solution, 
preferably in milk. 

The treatment which has thus been detailed is that of a case of syph- 
ilis which pursues a favorable course and does not develop any severe 
local manifestations or derangement of the health or digestion. If such 
manifestations occur, modification of the treatment is usually necessary. 
Large or small doses of the mercurials may be given, or large or small 
doses of the iodides may be required. 

It is sometimes advantageous to abandon temporarily the use of mer- 
cury, as it seems at times almost to lose its effect upon the system. Under 
such circumstances it is best to give the patient a course of the iodide 
and then to return to the mercury. Often, especially in the advanced 
stages of the disease, a mixed treatment with the mercury and the iodide 
is advantageous. 

When, owing to the involvement of some important organ in a syph- 
ilitic lesion, special accidents occur in syphilis, the principle of treatment 
is to meet such accident as it would be met if it arose from other cause, 
and at the same time to push actively antispecific medication. If the 
syphilis dangerously involve any vital organ, mercury should usually be 
administered in large dose at once, so as to remove the gumma and pre- 
vent the secondary effects of pressure or of inflammatory involvement. 
These principles will be found worked out in some detail in the article on 
Cerebral Syphilis, to which the reader is referred. The methods of iner- 
curialization by inunction and by hypodermic medication are also de- 
scribed there. 

The only preparation of mercury which should be used hypodermically 



320 



GENERAL, DISEASES. 



is corrosive sublimate. Very many other simple and complicated prepa- 
rations have been recommended from time to time, but are of inferior 
value. The rule in syphilis is that cachexia contra- indicates the use of 
mercurials ; yet we have often seen syphilitic cachexia yield rapidly to 
the combination of corrosive sublimate with tincture of chloride of iron, 
and we consider it an axiom that when in syphilitic cachexia there is a 
very pronounced ansemia such combination should be used. 

Mercurialization may be produced by the process of fumigation, either 
with calomel or with cinnabar. The method is especially useful in cases 
of syphilitic eruptions. The patient should sit upon a stool or chair, 
enveloped with a blanket tightly secured around the neck and spread out 
below in the manner of a tent. Beneath the chair the mercurial is 
volatilized on an ordinary tin plate with a lamp underneath it. Various 
patterns of lamps are furnished by instrument-makers, but the simple 
spirit-lamp set upon a plate, with an ordinary chemical tripod over it, 
will suffice. 

The general tendency of syphilis is to the breaking down of the con- 
stitution, so that during antisyphilitic medication it is essential that the 
bodily health of the patient be maintained by hygienic and other means. 
According to our experience, syphilitic diseases in the woman are prone to 
yield less readily than in the man, and especially to be connected with 
anaemia and exhaustion : so that, whilst very active specific medication is 
often necessary, great care must be taken, by the use of iron, tonics, and 
hygienic measures, to maintain the strength of the patient. 

In congenital syphilis the best treatment consists in rubbing the abdo- 
men of the child with mercurial ointment and covering it with a flannel 
smeared with the drug. If it be important not to arouse suspicion, mer- 
cury with chalk or other preparation may be given by the mouth ; later 
in the disorder the mixed treatment of mercury and iodide is very useful. 
The antispecific medication should be kept up at intervals for years, and 
the child should be especially watched at the period of the second den- 
tition and at puberty for the development of lesions, whose presence will 
be the signal for immediate active medication. 



DISEASES DUE TO ANIMAL PARASITES. 



321 



CHAPTEE IY. 

DISEASES DUE TO ANIMAL PARASITES. 

A variety of animal parasites find their host in man, are nour- 
ished at his expense, and either produce little or no disturbance or 
give rise to grave, if not fatal, disease. In their structure they vary 
from the simplest forms of animal life to those more highly differen- 
tiated. As a rule, they enter the body in food or drink, and either 
remain permanently in the intestinal canal, or, migrating from this 
region, are to be found even in the remotest parts of the body ; while 
other parasites infest the skin, are incapable of extensive migration, and 
produce simply local disturbance. In our consideration of the subject 
we have closely followed Mosler and Peiper. 

PARASITIC PROTOZOA. 

Of the lowest form of animal life, the protozoa, several varieties 
occur among human parasites. One of the most important of these is 
the Amoeba coli or dysenteriw, which plays an important part in the pro- 
duction of dysentery. (See page 213.) Amoebae have also been found 
in the urine, as a rule in connection with hseinaturia, with or without 
evidences of nephritis. In one case there was hemorrhagic cystitis, 
and the wall of the bladder was thickened and contained amoebae in 
abundance. 

The sporozoa form a group closely allied to which are the hwmatozoa, 
the description of which is to be found in the article on malaria, page 203. 
The Coccidium oviforme, one of the sporozoa, has proved a cause of death 
in man, in whom it is rare, although it is of frequent occurrence in rabbits, 
cats, dogs, and other domesticated animals. According to Leuckart, the 
amoeboid young coccidia enter the epithelium of the intestine and bile- 
ducts and form capsules in which are developed numerous spores, whence 
the term sporozoa, which are locally multiplied or transferred elsewhere 
after the capsules break. Collections of the coccidia are to be found in 
the epithelium of the intestinal wall and in the liver of rabbits, in the 
latter forming opaque yellow or white tumors. In man a number of 
tumors of a similar character were seen by Gubler, and Leuckart recog- 
nized coccidia in them. Since then collections of this parasite have been 
observed not only in the liver, but also in the intestinal mucous mem- 
brane, in the myocardium, and in pleuritic exudation, although in gen- 
eral no symptoms have been attributed to their x^resence. Podwyssozki 
has reported four cases in which the coccidia were present in the liver, 
not only in nodules but also in the hepatic cells, and were regarded as 

21 



322 



GENERAL DISEASES. 



the cause of an associated jaundice and cirrhosis. Beference may be 
made to the presence of hyaline bodies in the disease of the skin called 
by White keratosis follicularis, in niolluscuni contagiosuin, in Paget' s 
disease of the nipple, and in epidermoid cancer. These bodies have 
been regarded as psorosperms or sporozoa, and have been considered 
as the cause of the disease in which they were found, and their presence 
has been assumed as directly favoring the theory of the parasitic origin 
of cancer. Although observers are not wholly agreed upon their nature, 
it is generally conceded that they represent simply a hyaline metamor- 
phosis of epithelial cells. That sporozoa may be of importance in human 
pathology is evident from the cases described by Eixford and Gilchrist. 
Nodules had existed in the skin for a period of months or years, the 
lymph-glands were enlarged, and sporozoa inoculable in rabbits and dogs 
were obtained from the skin, from lymph-glands, and from tuberculoid 
nodules in the lungs, spleen, liver, adrenals, and testis. 

The infusoria form another group of the protozoa important in human 
pathology. The flagellate infusoria include the Megastoma entericum or 
Lamblia intestinalis, the Cercomonas intestinalis and Cercomonas coli hominis, 
the Trichomonas intestinalis and Trichomonas vaginalis. "With the exception 
of the last, these parasites have been recognized in the intestinal contents 
in a variety of diseases. They have likewise been found in the nose, in 
the mouth, and, according to Osier, in the vomit, also in gangrenous lung 
and in pleuritic exudations. Their presence in enormous numbers in the 
intestinal mucus of children and adults suffering from chronic diarrhoea 
and dysentery indicates that they may be of pathogenic importance, 
whether as a cause or as a complication. Dock has recently reported 
a case of trichomonas in the urine, the parasite being regarded as the 
cause of the associated inflammation of the bladder and hematuria, 
He suggests that the presence of this parasite should be sought for in 
hematuria, so often in the South attributed to malaria, especially when 
independent of other symptoms of the latter affection. 

Of the ciliated infusoria the Balantidium coli has attracted attention 
from having been found in the stools of dysentery. According to Hosier 
and Peiper, twenty -eight cases have been observed, most of them occurring 
in the vicinity of Stockholm, although two of the patients are said to 
have been infected in the United States. The pathogenic importance of 
this parasite is still in doubt, but in the reported cases it has been 
observed that an exacerbation of the diarrhoea was associated with an 
increase in the number of the infusoria in the stools. 

HELMINTHIASIS. 

Definition. — The disturbances produced by parasitic worms. 

The varieties of verminous parasites found in man are the tape-worms, 
or cestodes, the flukes, or frematodes, the leeches, or anellides, and the 
round and thread worms, or nematodes. 



DISEASES DUE TO ANIMAL PARASITES. 



323 



TAPE-WORMS. 

The cestoid parasites include the several varieties of taenia, or tape- 
worm, which prove injurious to man by their presence in the intestine, 
and especially by their occurrence in the larval stage in the various 
organs and tissues of the body. From the mature worm which lives in 
the intestine of man or of a lower animal are discharged eggs either 
free or included within the proglottides or segments. If these eggs 
are swallowed by man or a suitable lower animal, the envelopes are 
digested and the embryos set free. The latter penetrate the walls of 
the blood-vessels and lymphatics, and are then carried to various parts 
of the body, in which their development into cysts, the cysticerci or 
echinococci, takes place. These cysts are the larvae of the tape- worm, 
and when swallowed become the tape- worm. The taeniae of most fre- 
quent occurrence in man are the Tcenia solium and the Tcenia saginata. 

Taenia Solium. — The taenia solium, or pork tape-worm, six to nine 
feet long, has a round head about the size of a pin's head, armed with 
twenty-six hooklets in a double row, rising from a pigmented base, and 
provided with four suckers. The narrow neck soon becomes trans- 
versely lined, an indication of the formation of segments, which, some 
three feet from the head, instead of being elongated are square. In 
the fully developed segments, from the four hundred and fiftieth down- 
ward, both the male and the female generative organs are found, and 
the uterus is readily seen, on pressure of the proglottid between plates 
of glass, as an arborescent figure with a central trunk, from each side 
of which eight or ten lateral branches project. From the border of 
the segment projects a small elevation, the genital opening, out of which 
the ova, which exist to the number of thousands, may be pressed as 
an opaque fluid. After the tape-worm has been three or four months 
in the intestine the mature segments, nine to ten millimetres long and 
six to seven millimetres wide, may be found in the stools. They are 
frequently misshapen, from partial or complete fusion, from the presence 
of lateral buds, or from perforation. From the eggs taken into the 
stomach of man, swine, sheep, dog, and rat is developed the Cysticercns 
cellulosce to be found in various parts of the body ; in swine the condition 
thus produced is called measles. 

The Tcenia solium lives in the middle of the small intestine, to the wall 
of which it clings by its hooklets, and may remain alive for several days 
after the death of its host. Although usually found alone, several may be 
present, and Kleefeld observed forty- one in the same individual. They 
may lie outstretched in the intestine, the head uppermost, or may form a 
complex knot ; and at times, through a reversion of peristalsis, segments 
may be vomited. The Twnia solium is very common in Central Germany, 
in which country raw or insufficiently cooked pork is often eaten, and 
from one-third to one-half of the patients seeking hospital aid for various 



324 



GENERAL DISEASES. 



purposes harbor the parasite. In regions in which pork is but little 
eaten, or in which cooking or various methods of its preservation have 
destroyed the vitality of the eggs, the pork tape-worm is relatively 
uncommon. 

Taenia saginata or mediocanellata, the beef tape-worm, is twelve to 
twenty -four feet long, and has a square, pigmented head, as large as that 
of a pin, provided with four suckers, but free from hooklets. The neck is 
short, the mature segments sixteen to twenty millimetres long and four to 
seven millimetres wide. The uterus has twenty to thirty lateral branches, 
which are usually dichotomous. The position of the genital opening 
and the irregularity in the development of the segments are the same 
as in the case of the Taenia solium. The cysticercus of this worm is rarely 
found in man, but usually develops in the muscles and viscera of cattle, 
in which it is often overlooked from its small size and its rapid shrinkage 
when exposed to the air. 

The Taenia saginata clings to the wall of the small intestine by means 
of its suckers, and abounds in those countries in which beef is the chief 
article of animal food. It is, therefore, the common tape-worm of the 
United States. Its propagation in man is dependent upon the use of raw 
or insufficiently cooked beef. 

The Taenia elliptica or cucumerina has been found in infants and young 
children, but abounds in dogs and cats, the embryos being harbored in 
lice and fleas. The Taenia nana has also been repeatedly found in chil- 
dren. There are a few instances of the occurrence of the Taenia jlavo- 
punctata, and Weinland and Leidy have found it in this country. Eats 
and mice are the usual hosts, the embryos developing in insects. In the 
East the Taenia Madagascar iensis has been found, and Weinland described 
the presence in a Virginian of the cysticercus of the Twnia acanthotrias, 
although its mature tape-worm has not been found. 

The Bothriocephalus lotus, or fish tape- worm, is fifteen to twenty-seven 
feet long, and has a club-shaped head, without suckers or hooklets, but 
provided with two lateral grooves. The proglottides are broad and short. 
The eggs escape into the intestine from the ripe segments, and are further 
developed in water. They are swallowed by the pike, perch, salmon, and 
turbot, in the flesh and viscera of which, according to Braun, the embryos 
are found, and from which the mature worm has developed in dogs, cats, 
and man. In regions where improperly cured fish is eaten, especially 
along the Baltic, in Bavaria, and in Switzerland, this worm abounds. 
Odier states that in Geneva twenty-five per cent, of the population harbor 
this parasite. 

The Bothriocephalus cordatus and the Bothriocephalus cristatus may be 
mentioned as of rare occurrence, while the larval stage of the Bothrio- 
cephalus liguloides has been observed in China and Japan. 

Etiology. — The tape- worms of man, according to the variety, are de- 
rived from raw or insufficiently cooked or preserved beef, pork, and fish. 



DISEASES DUE TO ANIMAL PARASITES. 



325 



Tliey are more frequent in men than in women, and abound during the 
middle third of life, although common among children, and Mensinga 
found the tape- worm in an infant of ten weeks. Mosler and Peiper state 
that butchers, innkeepers, waiters, cooks, and housemaids are especially 
apt to be affected. 

Symptoms. — The parasites may be harbored for years, especially by 
robust individuals, without producing any disturbance, but sensitive per- 
sons, particularly women, are likely to suffer various symptoms, notably 
after the existence of the tape- worm has been discovered. Even before 
its presence is recognized such persons may be ansemic, easily tired, and 
subject to digestive derangements. Whatever irregularities of digestion 
arise after the recognition of the presence of the tape- worm are invari- 
ably attributed to its presence. The appetite often becomes feeble or 
capricious, but more frequently is excessive. Nausea, vomiting, and 
the regurgitation of gas and a bitter or acid fluid occur. Attacks of 
colic arise without apparent cause ; existing diarrhoea or constipation 
is often attributed to movements of the worm, which are frequently 
asserted to be aggravated by certain kinds of food and assuaged by 
agreeable articles of diet. Women who have borne children have stated 
that the movements of the tape-worm in the bowel simulate those of the 
foetus in the uterus. Numerous disturbances of the nervous system are 
attributed to the parasite, and are regarded as of a reflex nature. Such 
are mental and physical sluggishness, often suggesting melancholia and 
hypochondriasis, while vertigo, fainting, disturbances of sight and hear- 
ing, irregular pupils, hiccough, cramps, and convulsions are said to 
be caused by the tape- worm, and often disappear when the parasite is 
removed. The importance of the idiosyncrasy of the patient in ac- 
counting for the severity of the symptoms is obvious from the facts of 
their limitation to persons of sensitive nervous temperament, their cus- 
tomary origin after the discovery of the tape- worm, and their presence 
in persons free from the parasite. 

The Bothriocephalus lotus, in particular, has been frequently found in 
persons showing a marked degree of ansernia. Palpitation, dyspnoea, 
loss of flesh and strength, and perhaps fever, may be so severe as to 
confine the patient to bed, and retinal hemorrhages and dropsy may be 
present. The resemblance of these symptoms to those of progressive 
pernicious ansemia is intimate, and in certain cases they are relieved by 
the expulsion of the parasite, while in others improvement does not MIoav 
this result. The question is, therefore, still undecided as to the signifi- 
cance of the Bothriocephalus in the production of the associated anaemia. 

The discovery of the tape-worm is usually made by the observation of 
segments in the stools, although they may escape from the bowel at other 
times than during defecation, and then attract attention by the associated 
itching near the anus, or by the sensation of a smooth and slippery body 
upon the skin of the buttocks or thigh. They have escaped through the 



326 



GENERAL DISEASES. 



abdominal wall from intestinal fistulse, have been voided with the urine 
in cases of vesico-intestinal fistulse, and have been vomited. The tape- 
worm may exist for years (thirty-five years in one instance being 
reported), and the passage of segments may be observed only at rare 
intervals, while their evacuation is said to be promoted by a diet con- 
taining fruit and salted, pickled, or spiced articles of food. 

Diagnosis. — The presence of the tape-worm in the intestine is to be 
recognized only by the discovery of the segments or of the eggs, and their 
evacuation may be promoted by the use of a brisk cathartic. The seg- 
ments of the pork-worm are generally more intimately mixed with the 
faeces than are those of the . beef- worm, which, being more numerous, are 
more likely to escape at other times than during defecation. The pro- 
glottides of the Bothriocephalus are usually discharged as a coherent band 
of considerable length. The difference between the segments of the 
Tcenia solium and of the Tcenia saginata is readily appreciated when they 
are compressed between glass plates. The former are more transparent, 
and the uterus has about ten lateral branches, while that of the latter 
has in the vicinity of eighteen. The segments of the Bothriocephalus are 
short and broad, in the middle of which the uterus forms a rosette. 

Prognosis. — Tape- worms are rarely dangerous to their host, the 
Tcenia saginata, or beef -worm, being the least harmful. The Twnia solium 
may become dangerous if its mature segments enter the stomach during a 
reversal of intestinal peristalsis and become digested, since the embryos 
are then set free and may become cysticerci. The Bothriocephalus lotus . 
may prove a source of profound anseniia. 

Treatment. — The chief drugs which are used against the tape- worm 
are pumpkin seed, the oleoresin of male fern, pomegranate rind and its 
alkaloids, pelletierine and isopelletierine, kousso and its active principle, 
tseniin or koussin, turpentine, and thymol. Whatever drug be selected, it 
is necessary to see that the intestinal canal is as free as may be from con- 
tents which should protect the worm. The patient should take a brisk 
cathartic thirty-six hours before the anthelmintic, be put on milk diet 
for twenty -four hours, and left entirely without food during the morning 
of exhibition. We have usually employed pumpkin seed (pepo). Two 
ounces of it may be made up in an electuary, with sugar and aromatics. 
Having on Sunday night taken a cathartic and on Monday no food but 
milk, and none of that after six o'clock in the evening, the patient on 
Tuesday morning should breakfast on the pumpkin seed confection, with, 
if desired, a cup of coffee. Three hours subsequently half an ounce to 
an ounce of castor oil, with two drachms of oil of turpentine, should 
be taken. If the subject be feeble, the turpentine may be omitted. 
Purging will usually come on in two or three hours, and at this time 
about a quart of saturated watery solution of ordinary salt should be 
thrown into the large intestine, so as to aid in the expulsion of the 
worm. In a robust, obstinate case one-half to one drachm of the oleo- 



DISEASES DUE TO ANIMAL PARASITES. 



327 



resin of fern may be taken two hours after the ingestion of the pumpkin 
seed, and followed in two hours by castor oil. 

Pomegranate rind is a very efficient vermifuge : bark which is in 
small thin quills is believed to be more active than the larger, pieces. 
The decoction may be made by boiling two ounces of the bruised drug 
after maceration for twenty-four hours in two pints of water to one pint. 
A wineglass of this is to be taken every half-hour until the whole has 
been taken or violent purging has been produced. If purging do not 
occur, the last dose should be followed shortly by castor oil. The alkaloids 
of pomegranate are chiefly used in the form of a tannate : as put on the 
market by Tanret, their discoverer, each bottle contains one dose, about 
five grains. The dose of pelletierine tannate as furnished by Merck 
is set down at from eight to twenty-four grains in an ounce of water, 
to be followed in an hour by a brisk cathartic. Taeniin is stated by 
European writers to be very efficient given in doses of twenty to forty 
grains, followed in two hours by a cathartic. 

Of the tsenicides just mentioned, pepo is, so far as known, harmless 
to man. The oleoresin of male fern has in several cases caused death, 
with symptoms of violent vomiting and purging, attended by failing 
strength, stupor deepening into coma, motor excitement amounting, it 
may be, to violent tetanic convulsions, and in the end collapse. A fatal 
result is said to have been produced by a little over a drachm. Six 
drachms have in several cases caused death in the adult. Pelletierine, 
being a nerve paralyzant, is probably capable of taking life, though no 
cases of serious poisoning by it appear to be on record : we have seen 
a startling general paralysis follow the use of the French preparation in 
a feeble woman. 

CYSTICERCUS DISEASE. 

This affection is due to the presence in the body of the Cysticercus 
cellulosce, the larval stage of the pork tape-worm, resulting from the en- 
trance of the ova of the Taenia solium into the stomach ; the cysticercus of 
the beef tape-worm and that of the fish tape-worm have rarely, if ever, 
been found in man. These eggs are usually derived from the tape-worm 
of another host, although it is possible, as has already been stated, that 
with the entrance of intestinal contents into the stomach the ripe seg- 
ments of the harbored tape-worm may be admitted and their ova set free. 
In children, in persons of uncleanly habits, and in the insane, who may 
be hosts of a tape-worm, it is possible that an auto-infection may take 
place by the manual transfer of the ova from the anus to the mouth. In 
most cases, however, they are derived from the tape- worm of another 
host, Huber stating that in thirty persons only has the combination of 
cysticercus and tape-worm been observed. The cysticerci occur oftener 
in men than in women, usually in middle life, although they have been 
observed at all ages, even, according to Dressel, in the infant a few days 
old, in which case the ovum must have entered the foetus. When the 



328 



GENERAL DISEASES. 



embryo, armed with booklets, is set free by the digestion of its capsule by 
the fluids of the stomach, it bores into the wall of the alimentary canal 
and enters the lymphatics or blood-vessels, Leuckart having found them 
in the portal blood, and is transferred to various parts of the body. As 
the embryo reaches its resting-place its hooklets are shed, it increases 
in size, and is transformed into a cyst containing a clear fluid, which is 
usually as large as a pea, but may become of the size of a pigeon's egg, 
provided it has room enough in which to grow. An opaque spot on its 
wall indicates the seat of an inverted portion, at the bottom of which in 
the course of three months is developed a head with suckers and hook- 
lets, which may be everted by pressure upon the cyst. The cysticercus 
usually lies in a fibrous capsule formed from the surrounding connective 
tissue, but in spaces of large size, as cerebral ventricles and the interior 
of the eye, it may be free, and Zenker observed one lying in a small 
aneurism at the base of the brain. It may also be free in the large 
lymph-spaces of the cerebral pia mater, in which it becomes flattened 
and irregularly lobulated in consequence of the structure of the commu- 
nicating spaces in which it is contained. Such a cysticercus is called 
racemose. The cysticercus once lodged usually remains fixed, although 
when in the eye movements of its head have been observed with the 
ophthalmoscope, and it is considered that migration is possible provided 
there is no mechanical obstruction, as in a large space. It may live for 
years, and one has been under observation in the eye for twenty years. 
The cysticercus may occur alone or be present in numbers, especially 
in the muscles and in the subcutaneous tissue, Bonhomme having counted 
two thousand in the subcutaneous tissue and nine hundred in the muscles 
of a patient seventy-seven years old. According to Dressel, the organ in 
which they are most often found is the brain, usually in the membranes 
and cortex, especially in the fissure of Sylvius. They are also relatively 
frequent in the eye, Von Graefe having observed eighty cases, and they 
have been observed in the heart, lungs, liver, kidneys, and bones. 

Symptoms. — There may be numerous cysticerci in the body and no re- 
sulting disturbance, or a single cysticercus may give rise to the severest 
symptoms. Of especial importance is the organ in which the parasite 
lies and the part of the organ it occupies : hence invasion of the brain and 
cord is more likely to produce disturbance than of the skin and muscles, 
although in the former there may be but a single cyst and in the latter in- 
numerable cysts may be present. In animals the sudden entrance of large 
numbers of embryos is associated with fever, prostration, pain, and diar- 
rhoea, and death may soon follow, in which event the heart and muscles 
have been found speckled with minute cysticerci resembling tubercles. 
The cerebral cysticerci may cause chronic meningitis and hydrocephalus, 
and thus may prove a source of headache, dizziness, mental and physical 
prostration, convulsions or paralyses ; while the cysticercus in the eye 
occasions disturbance of vision. Although numerous cysticerci may be 



DISEASES DUE TO ANIMAL PARASITES. 



329 



found in the muscles without resulting disturbance, the observation of 
animals suggests that contraction of the muscles may become difficult and 
painful ; indeed, Osier describes the case of a patient in whom difficult 
locomotion, soreness and stiffness of the muscles, numbness, and tingling 
were attributed to cysticerci in the muscles and skin, since they were found 
in numbers beneath the latter. Cysticerci of the skin are manifested by 
subcutaneous tumors, either solitary or in large numbers, smooth, round, 
and elastic, perhaps sensitive, not projecting above the surface, some- 
times as large as a walnut. They may produce numbness and pain by 
pressure upon the peripheral nerves, and have caused a diagnosis of 
neuritis. Cysticerci of the heart usually give rise to no symptoms, 
although when seated in the wall palpitation, dyspnoea, angina, and 
dropsy may result, while pedunculate cysticerci within the cavity of the 
head may cause valvular obstruction or incompetency, or be torn off 
and produce embolism. The cysticerci in other organs usually produce 
little or no disturbance, the larvae dying and becoming calcified. A bac- 
terial infection of the fibrous capsule may occur and an abscess result. 

Diagnosis. — The presence of the cysticercus is recognized by the dis- 
covery of the parasite, which takes place when it is seen in the eye or 
found in a tumor removed from the skin or muscle. 

Prognosis and Treatment. — Cysticerci may be inconvenient in the 
muscles or skin, but are a source of danger only when in the heart and 
brain. In the eye they are usually productive of local disturbance alone. 
The only radical treatment is surgical removal. 

ECHINOCOCCUS DISEASE. HYDATID DISEASE. 

The echinococcus, or hydatid, is the larva of the Tcenia echinococcus, a 
tape- worm of the dog, wolf, jackal, and fox, and is rarely, if ever, found 
in man, although its presence in the eye, presumably directly transferred 
by a dog's tongue, has been recently recorded. This worm easily escapes 
notice, as it is only four or five millimetres long, and appears as a small 
white thread. The head has four suckers and from twenty to thirty hook- 
lets in a double row, while there are but three or four joints attached, 
only the last of which contains productive eggs. When the eggs are 
swallowed by man or certain of the lower animals, either wild or domes- 
ticated, the embryos are set free, make their way into the lymphatics and 
blood-vessels of the intestinal wall, and by means of the circulation are 
carried to various parts of the body, in which they become transformed 
into the echinococcus cyst or hydatid. Their usual seat is the liver, and 
they are also to be found in the mesenteric glands and the peritoneal 
cavity ; more rarely, if the general circulation is entered, through either 
the hepatic vein or the thoracic duct, the hydatids are to be found in the 
lungs, heart, brain, spleen, uro genital apparatus, muscles, or bones. The 
disease abounds in countries, as Australia and Iceland, in which dogs are 
numerous. It is also frequent in various parts of Europe, and Osier has 



330 



GENERAL DISEASES. 



collected evidence of eighty-five cases in the United States and Canada. 
It prevails especially among those of uncleanly habits who are intimately 
associated with the dog, as children and shepherds. In Iceland about 
one- eighth of the population suffer from hydatids, and eight per cent, of 
the patients are children. The symptoms of the disease usually appear 
during the middle third of life, the sexes being affected with equal fre- 
quency. 

Morbid Anatomy. —After the embryo becomes lodged at any par- 
ticular part of the body it is gradually transformed into a cyst. One or 
many cysts may be found, according to the number of embryos admitted 
into the circulation ; they are unilocular or multilocular, the latter 
variety being found almost exclusively in the liver, although in rare 
instances it has been seen elsewhere. In the course of four or five 
months after lodgement the cyst may become as big as a walnut, and it 
may eventually form a tumor larger than a child's head, lying free within 
a capsule formed from the fibrous tissue of the body. These cysts are 
either sterile, acephalocysts, a variety rare in man, or reproductive of 
successive generations of cysts. The wall of the maternal cyst is lamel- 
lated, and from the inner or parenchymatous layer hollow buds, daughter 
cysts, project into the cavity, and from the interiors of these buds heads, 
or scolices, provided with suckers and hooklets, arise by the inversion 
of a portion of the wall. This method of growth is called endogenous, 
in contradistinction to the production of buds or sprouts from the outer 
surface of the wall, the exogenous growth which occurs in the echino- 
cocci of cattle and swine. The daughter cysts may become detached 
from the parent cyst and float within its cavity, or when in large num- 
bers so fill the parent cyst as to leave but little room for fluid, while the 
scolices may be formed by the thousand. 

The multilocular echinococcus appears as an irregular mass proceed- 
ing from the liver, and may develop into a tumor as large as a child's 
head. It is traversed by fibrous septa enclosing alveoli in which are 
collections of transparent gelatinous material, sterile cysts. This variety 
was formerly regarded as alveolar cancer, but Yirchow discovered that 
the tumor was due to the echinococcus. It is considered probable that 
the peculiar appearance of the parasite is due to the growth of the cyst 
in lymph-vessels, blood-vessels, or bile-ducts, along the branches of which 
it is continued. 

The contents of the cyst are a clear, pale-yellow fluid of neutral re- 
action and a specific gravity of 1005 to 1015, not coagulating with heat. 
Chlorides are abundant. There may be a trace of sugar, and the pres- 
ence of succinic acid is shown by the production of a brown color on 
the addition of a dilute solution of ferric chloride. That the fluid is 
toxic is evident from the symptoms which follow rupture, and Brieger has 
found a toxin which rapidly destroys mice. The echinococcus may die 
either from injury or from acute or chronic inflammation of its capsule, 



DISEASES DUE TO ANIMAL PARASITES. 



331 



and the presence of bile may kill the liver echinococcus. After its death 
more or less fluid is absorbed, and the wall becomes corrugated and 
encloses a grease in which fat- drops, fat-crystals, and hooklets are to be 
found. On the inner surface of the fibrous capsule of the echinococcus 
of the liver crystals of haematoidin or bilirubin are often found. The 
shrivelled dead echinococcus may become infiltrated with lime salts and 
form a concretion in which hooklets may be seen after removal of the 
lime. The more numerous and the larger the echinococcus cysts the more 
likely is the occurrence of atrophy of the cells of the organ in which the 
parasites lie. According to Neisser, the relative frequency of echinococci 
in the various organs is as follows : liver fifty per cent., kidneys eight 
and nine-tenths per cent., cranium seven and five-tenths per cent., lungs 
seven and four-tenths per cent., female genitals and mammae four and 
nine- tenths per cent., pelvis four per cent., circulatory apparatus three 
and two-tenths per cent., spleen three per cent., face, orbit, and mouth 
two and three- tenths per cent. , spinal canal one and nine-tenths per cent. 
Usually but one organ is affected, although hundreds may be found in the 
peritoneal cavity, and their presence in numbers is probably due to the 
simultaneous entrance of many embryos or to their multiple escape from 
the rupture of productive secondary cysts. 

Symptoms. — The invasion of the embryos often causes no known 
symptoms, probably from the rarity of a manifold infection, which in 
dogs produces symptoms resembling those of rabies. The echinococcus 
cyst may give rise to no disturbance, it having been found after death of 
such size as must have been the result of years of growth, although its 
presence during life had been wholly unsuspected. When symptoms 
occur, they are due to the pressure of the cyst upon surrounding parts, 
to its rupture, or to the suppuration of its capsule, and their severity 
varies largely in accordance with the size and seat of the cyst and the 
organ concerned. The large hydatid of the liver may produce but little 
disturbance, while a small cyst in the brain may prove rapidly fatal, 
and cysts pressing on the spinal cord cause paralysis, while hydatids of 
bone have led to spontaneous fracture. When perforation of the capsule 
takes place, the contents of the cyst may escape into the alimentary 
canal, into the uro-genital tract, into the bronchi, or through the skin. 
Perforation may also take place into the serous cavities, with the pro- 
duction of severe disturbances, dependent upon the toxic nature of the 
fluid, or into the blood-vessels, and cause death from embolism or tox- 
aemia. Suppuration of the fibrous capsule of the cyst results in the for- 
mation of abscesses, which are manifested by chills, fever, localized pain, 
progressive emaciation, debility, and perhaps jaundice. Death from 
pyaemia or septicaemia is the frequent result. 

These general symptoms are associated with the presence of a tumor 
sometimes larger than a man's head, flat on percussion, and, when tan- 
gible, usually sharply defined, rounded, smooth, elastic, fluctuating, and 



332 



GENERAL DISEASES. 



sometimes presenting a thrill suggestive of quivering jelly. This hyda- 
tid thrill is of no pathognomonic importance, since it is frequently 
absent, and since a similar sensation is sometimes obtained from ascitic 
fluid or from the contents of an ovarian cyst. Especial symptoms due 
to the presence of the echinococcus in any particular part of the body 
will be mentioned in the consideration of the regional distribution of the 
parasite. 

Localization of the Echinococcus. 

Echinococci of the Nervous System produce symptoms such as are 
caused by similarly located tumors. 

Echinococci of the Heart. — Echinococci of the heart are rare. 
The cysts project either from the surface of the heart or into the cavities, 
more frequently of the right side, and either produce no symptoms, or 
cause sudden death from embolism, either by detachment of the cyst or 
by its rupture and escape of the contents. 

Echinococci of the Lungs and Pleura. — Echinococci of the lungs 
produce no symptoms until they attain a size sufficient to cause com- 
pression of the lung or perforation of a bronchus, when inflammation, 
gangrene, and empyema may arise. These results also follow perforation 
of the diaphragm and lung by an echinococcus of the liver or kidney. 
When the cyst ruptures into the pleural cavity, there are sudden pain and 
dyspnoea, and sometimes urticaria ; pleurisy, perhaps empyema, is the 
constant outcome. Perforation of the pulmonary vessels has led to embo- 
lism and fatal hemorrhage. The growth of the pulmonary echinococcus 
may be manifested by cough, pain from associated pleurisy, dyspnoea, 
fever, and emaciation, symptoms suggestive of phthisis. When the 
echinococcus is in the upper lobe there may be haemoptysis and signs of 
consolidation, yet the nutrition of the patient remains undisturbed. The 
absence of characteristic bacilli becomes important in differential diag- 
nosis, although tuberculosis and echinococcus may coexist. When echi- 
nococci develop in the pleural cavity the symptoms resemble those of 
hydrothorax, and there are displacement of the heart and diaphragm 
and retraction of the lung corresponding to the size of the cyst. 

Echinococcus of the Liver. — When hydatids of the liver are of a size 
sufficient to produce symptoms, enlargement of the organ results, either 
local or general, and the cyst may project from the surface as a rounded 
or pedunculate tumor, or the boundaries of the liver may extend from 
the second rib to the crest of the ilium. Single echinococci are more 
often found in the right than in the left lobe. A sensation of weight and 
pressure in the epigastrium and right hypochondrium may be present, 
and the upward displacement of the diaphragm may cause dislocation of 
the heart, compression of the lung, and dyspnoea. Pressure upon the por- 
tal vein produces ascites, while, if the hepatic vein or the inferior vena 
cava is compressed, oedema of the legs results. The larger bile- ducts may 
become obstructed and jaundice follow. Rupture of the cyst may take 



DISEASES DUE TO ANIMAL PARASITES. 



333 



place into the pleural, pericardial, or peritoneal cavity, often producing 
serious, if not fatal, acute inflammation. If the pleural cavity has been 
previously obliterated and rupture into the lung occurs, pneumonia is 
likely to follow, perhaps terminating in abscess or gangrene, with ex- 
pectoration of pus or blood and bilirubin crystals, and the patient may 
cough for months and even recover after ejecting cysts, scolices, or hook- 
lets. Perforation into the gall-bladder has been followed by symptoms 
suggestive of gall-stones, and perforation into the stomach or intestine 
has led to the discharge of cysts through the mouth or anus. Eupture 
of the cyst into the hepatic vein or the inferior vena cava has caused im- 
mediate death by hydatid embolism of the heart and pulmonary artery. 
Cysts have escaped with the urine when perforation has taken place 
into the renal pelvis, and hydatids have been discharged through a fis- 
tulous opening in the abdominal wall. When the cyst suppurates, the 
characteristics of an hepatic or a subphrenic abscess are produced, and 
the abscess, like the hydatid, may be evacuated into the regions above 
mentioned. 

The enlargement of the liver may be suggested by a bulging of the 
epigastrium or right hypochondrium. The area of hepatic dulness is 
increased in proportion to the size and situation of the hydatid. The 
upper line of thoracic dulness is likely to be convex, its highest point in 
the axillary region, and when the echinococcus cyst is largely developed 
in the subphrenic region the descent of the liver on inspiration is checked. 

The multilocular echinococcus is almost exclusively limited to the 
liver, and is of very rare occurrence ; when sufficiently large, it is likely 
to present the symptoms of fibrous hepatitis, such as gastro-intestinal 
hemorrhages, ascites, and perhaps jaundice, while enlargement of the 
liver and of the spleen is conspicuous. 

Echinococcus of the liver is to be diagnosticated by the recognition of 
the enlargement, usually circumscribed, of this organ, and the determina- 
tion of its cause by means of the aspirator. For a long time the strength 
and nutrition of the patient are well preserved : hence amyloid degenera- 
tion and cancer are easily excluded, and the persistent jaundice of hyper- 
trophic cirrhosis is lacking. An echinococcus projecting from the upper 
surface of the liver may simulate a pleuritic exudation, but the highest 
point of dulness from the latter is in the dorsal and not in the axillary 
region. Suppurating hydatids may be confounded with simple cyst of 
the liver, or with a subphrenic abscess, since the symptoms are the same 
and the physical manifestations may be identical. Dilated gall-bladder, 
cancer, hydronephrosis, and cystic kidney are excluded by examination 
of the aspirated fluid. 

Echinococcus of the Kidney. — The parasite occurs more often in 
the left kidney, and its growth tends to produce a cystic tumor sometimes 
of large size. With the increase in the size of the cyst the kidney be- 
comes atrophied, fatty degeneration of the epithelium with increase of the 



334 GENERAL DISEASES. 

■ 

fibrous tissue occurs, and pigment-granules from extravasated blood are 
often found in the vicinity of the cyst. Adhesions are likely to form 
between the peritoneal covering of the cyst and that of the spleen, liver, 
or intestine, and compensatory hypertrophy of the other kidney is fre- 
quently associated. The general health is unaffected, and especial symp- 
toms are usually delayed until perforation of the wall of the cyst, with 
escape of the contents, takes place. The renal pelvis is oftenest perfo- 
rated, but the cyst may rupture into the stomach, the intestine, or the 
peritoneal cavity, or through the diaphragm into the lungs. Perforation 
into the renal pelvis is followed by the escape in the urine of few or many 
cysts, perhaps at intervals, during months or years, the passage of the 
cysts being manifested by attacks of renal colic, and followed by reten- 
tion of urine, albuminuria, or hematuria, and symptoms of pyelitis or 
cystitis. The physical characteristics of the tumor resemble those of 
hydronephrosis, and the nature of the contents is to be determined after 
their withdrawal by means of the aspirator. The parasite may be present 
iri the kidney for thirty years, and, although rupture into the renal pelvis 
takes place in three-fourths of the cases, spontaneous recovery due to the 
death of the parasite can occur. The physical examination of the tumor 
gives evidence of its cystic nature, and its renal origin is determined by 
its position behind the colon and by its immobility. 

Echinococci of the Peritoneum. — The echinococcus may lie free in 
the peritoneal cavity, but it is more commonly situated in the subperi- 
toneal tissue, especially in the omentum and mesentery and in the wall 
of the pelvis. Hundreds of cysts may be present, resulting in abdominal 
tumors of large size. The growth is gradual, and usually without symp- 
toms until the movements of the diaphragm are interfered with, when 
respiration is disturbed, or the stomach and bowels are compressed or 
united by adhesions, with corresponding impairment of function. Eup- 
ture of the cyst and escape of the fluid into the peritoneal cavity are 
followed by the results already stated. Childbirth has been delayed 
and retention of urine produced when echinococci were in the pelvis, 
while extensive suppuration and death from septicaemia have followed 
perforation into the intestine or the vagina, although the passage of 
peritoneal echinococci into the hollow organs is rare. The physical ex- 
amination of the enlarged abdomen is indicative of the presence of fluid, 
while the gradual enlargement and absence of symptoms are suggestive 
of the presence of an ovarian or a parovarian cyst. The pelvis echi- 
nococcus rarely produces such large tumors as arise from the ovary or 
the parovarium. When the cysts are omental or mesenteric the limitation 
of the tumor at the outset to the upper half of the abdomen may suggest 
a cyst of the pancreas, but the growth of the latter is usually preceded 
by striking symptoms, and its presence is frequently associated with dis- 
turbance of digestion and discomfort. The characteristics of the aspirated 
fluid are sufficiently marked to establish the diagnosis. 



DISEASES DUE TO ANIMAL PARASITES. 



335 



Diagnosis. — The diagnosis ultimately depends upon the recognition 
of the tumor, which is of slow growth, usually painless, and generally 
without disturbance of nutrition. Its physical characteristics have 
already been described. More important is the determination of the 
nature of its contents, which are obtained by means of the aspirator. If 
the removed fluid is free from albumin, and contains sugar and succinic 
acid, or scolices, hooklets, or lamellated membrane, its echinococcal origin 
is obvious. Exploratory puncture, however, may prove dangerous by 
permitting leakage of the contents of the cyst into a serous cavity, in 
which case urticaria, dyspnoea, collapse, and fever may result. Aspi- 
ration should, therefore, be merely preliminary to treatment in case of 
doubt. 

Prognosis. — Although the conditions connected with its growth may 
promote the death or the evacuation of the parasite, they are more likely 
to threaten the life of the patient : hence with the establishment of the 
diagnosis the serious nature of the disease should be made conspicuous. 

Treatment. — Whenever the cyst becomes a source of discomfort its 
treatment by aspiration or removal becomes necessary. Aspiration has 
been frequently followed by complete cure, but is somewhat dangerous, 
and may prove ineffectual in retarding the growth of the cyst. Of late 
years cysts and complicating abscesses have been repeatedly opened, 
evacuated, and drained, with, as a rule, a favorable result. 

FLUKES. 

Of the trematoid worms dangerous to man those of especial importance 
are the blood-flukes, lung-flukes, and liver-flukes : the other varieties are 
of such rare occurrence as to require mention merely by name. Such are 
the JDistoma lanceolatum, Distoma crassum, Distoma heterophyes, Distoma 
ophthalmobium, Distoma sinense, Distoma conjimctum, and the Monostoma 
lentis. 

The Distoma hmmatobium, or blood-fluke, was discovered by Bilharz 
and Griesinger in the portal system and in the recto-vesical plexus. 
The female is sixteen to eighteen millimetres long, the male is some 
four millimetres less in length. The eggs are present as small white 
specks in the liver, in the intestinal wall, and especially in the urinary 
tract. This fluke prevails in various parts of Africa, particularly in 
Egypt, in which one-fourth of the native population, notably the poor 
and the children, are stated to harbor the parasite. It is supposed to 
live in the water of the Nile, and Europeans who use the filtered water 
rarely become diseased. The presence of the parasites in the mucous 
membrane of the bladder and ureters causes a hemorrhagic inflammation 
of the mucous membrane, within and upon which the eggs are to be 
found, having escaped from the blood-vessels. Necrotic patches infiltrated 
with urinary salts are to be seen upon the surface of the membrane, and 
pyelitis and nephritis may be associated. Eectal and vesical tenesmus, 



336 



GENERAL DISEASES. 



painful micturition, intermittent or persistent hematuria increased on 
exertion, hypogastric tenderness, progressive anaemia, and loss of flesh 
and strength result. 

Diagnosis. — The diagnosis is based upon the discovery of the eggs of 
the parasite, which are present in large quantities, chiefly in the blood- 
clots and slime in the sediment of the urine of persons suffering from 
cystitis and hematuria in the regions in which the parasites are found. 

The disease, distomiasis, may last for years without serious disturb- 
ance, the persons affected even being strong and vigorous, and the death 
of the parasite may occur with relief to the symptoms, especially after 
removal to a non-infected region. The severer manifestations arise among 
those exposed to repeated infection, and the course of the disease is that 
of an incurable cystitis or pyelitis, death resulting from uraemia or amy- 
loid disease. 

The Distoma pulmonale, or lung-fluke, according to Baelz and Manson, 
is frequently found in the bronchi of the natives of China, Japan, Corea, 
and Formosa. The parasite is probably derived from the drinking-water, 
and causes a cough with occasional haemoptysis, the diagnosis being 
established by the discovery of the eggs in the sputum. The parasite and 
eggs have been found also in the brain, liver, subperitoneal tissue, and 
intestinal contents. 

The Distoma hepaticum, or liver-fluke, is a flattened fluke of ellip- 
tical outline, about thirty millimetres in length, its greatest width being 
twelve millimetres : it is provided with two suckers. This fluke is very 
common in the bile-ducts of ruminants, but is rarely found in man, in 
whom it sometimes gives rise to jaundice and dropsy. 

In Japan, according to Baelz, the liver-fluke is productive among the 
natives of serious disease, essentially a chronic inflammation of the bile- 
ducts ; but the parasite has been found both in the subcutaneous tissue 
and in the liver. The embryos develop in snails, from which they are 
freed in the stomach of the host, and then wander through the bile-ducts 
into the liver, where hundreds may be present in the dilated bile-ducts. 
The liver is enlarged, its fibrous tissue is increased, and the liver-cells are 
atrophied. There is also enlargement of the spleen. The alterations of 
the liver are associated with a sense of pressure in the epigastrium, but 
progress for years with but little pain or general disturbance, and jaun- 
dice is usually absent. Eventually diarrhoea, intestinal hemorrhage, and 
ascites may result and death follow. 

The diagnosis is to be made by the discovery of eggs in the dejections. 

Medical treatment is only palliative, and consists in meeting symp- 
toms as they arise. 

LEECHES. 

Of the anellides or leeches there are two varieties, the Hirudo ceylonica 
and the Hirudo vorax, which are important as human parasites. The 
former is a land leech found in Ceylon, the Philippine Islands, Australia, 



DISEASES DUE TO ANIMAL PARASITES. 



337 



and Chili. It attaches itself to the skin, from which, if adherent, it must 
be removed with care, since if torn off a portion of the jaw is left, and 
causes chronic suppuration. The latter is a water leech found in Europe 
and North Africa. The young when swallowed may prove dangerous 
by causing hemorrhages and chronic disease of the larynx and trachea, 
which they may enter. 

ROUND AND THREAD WORMS. 

Of the nematoid worms parasitic in man one of the most common is 
the Ascaris lumbricoides, which somewhat resembles the earth-worm, and 
is pointed at both ends, of a yellowish color, the female being ten or 
twelve inches long and the male two to four inches less in length. The 
eggs are about six-hundredths of a millimetre long, and may be found in 
large numbers in the faeces, the female, according to Eschricht, annually 
producing in the vicinity of sixty millions. The embryos develop in 
warm and moist surroundings in the course of a few weeks or months. 
According to Grassi, twenty days after the embryos were swallowed by a 
child examination of the faeces was negative, but in two months numer- 
ous eggs were present, and in three months one hundred and forty -three 
worms were expelled. 

The ascaris is the most common verminous parasite of man, the symp- 
toms resulting from its presence receiving the term ascariasis. It is to be 
found at all ages, in both sexes, in all countries, and among all races, and 
is more frequently observed in children living in the country. The eggs 
are probably largely swallowed in drinking-water or with contaminated 
food, especially during summer. This worm lives in the small intestine, 
and the parasites may be present in large numbers, thousands having 
been expelled within a short time. They may wander from the small 
intestine to other parts of the alimentary canal, or through fistulous open- 
ings into other parts of the body. They generally survive the death 
of their host, after which they may migrate from the ileum. They are 
usually of but little symptomatic importance, but when numerous may 
produce loss of appetite, nausea, irregular movements of the bowels, and 
abdominal discomfort. In children, especially nervous children, restless- 
ness, irritability, picking at the nose, grinding of teeth, and disturbed 
sleep are attributed to the worms, and are frequently relieved after their 
removal. In rare instances they may form a mass causing a palpable 
tumor and producing intestinal obstruction. The migration of the worms 
becomes increased in severe febrile diseases, and in those characterized 
by frequent movements of the bowels, as typhoid fever, dysentery, and 
cholera. The wandering worms may enter the common duct and pass 
into the gall-bladder or into the hepatic ducts ; in the latter case abscesses 
of the liver may result. Vomiting may follow their appearance in the 
stomach and the parasites be expelled. According to Davaine, the as- 
caris has entered the Eustachian tube and the lachrymal canal, and has 

22 



338 



GENERAL DISEASES. 



frequently crawled out of the mouth, nose, or anus of a sleeping child. 
Dyspnoea, aphonia, immediate death from asphyxia, or a fatal bronchitis 
has resulted from its entrance into the respiratory tract. When discov- 
ered in the peritoneal cavity, a perforation should be sought for, either 
gastric, duodenal, appendicular, or typhoidal, through which it has passed, 
it being doubtful whether it can cause perforation of the intestine except 
a necrosis of the wall already exists. Migration through fistulous tracts 
between the intestine, pelvis of the kidney, bladder, female genital tract, 
and skin occurs. Usually the presence of the ascarides is first recognized 
after their escape from the bowel, although the examination of the faeces 
may lead to the discovery of the eggs. They are readily removed by 
appropriate treatment. 

Treatment. — ~No special diet or preparation is necessary in the use 
of remedies against the round worm. The number of vermifuges is quite 
large : those of the first rank are santonin, spigelia, oil of chenopodium, 
and turpentine. Of these santonin is probably the most effective. As the 
object is to bring it in contact with the worm and prevent absorption, 
the santonate should never be used, nor should the santonin be finely pow- 
dered. The official troches of santonin are distinctly inferior to lozenges 
made of the minutely crystalline, unpowdered drug. The best method of 
administration is, however, to give the santonin as it naturally occurs, 
along with calomel (two to six grains), in thick capsules, administered at 
bedtime, a brisk cathartic being exhibited in the morning if free purga- 
tion does not occur on waking. The dose of santonin for a child two 
years old is one-fourth to one-half grain. 

The fluid extract of spigelia and senna, formerly official, was a pleas- 
ant and effective vermifuge, especially in the case of children : dose for 
a child a year old, from forty-four to four hundred and forty minims, re- 
peated every four hours till it purges : to a child a year old, two drops 
of oil of chenopodium may be given three times a day for two days, and 
then repeated with a dose of castor oil. 

Oxyuris vermicularis. — The female thread- worm or pin -worm is ten 
to twelve millimetres long, and is about three times the length of the 
male. The eggs are five-hundredths of a millimetre long, and are pro- 
duced in abundance, from ten thousand to twelve thousand, according to 
Leuckart, being present in the female. When the eggs are taken into 
the stomach the embryos are set free by the digestive fluids, and so 
rapidly develop in the intestine that in the course of a fortnight the 
young worm has been found in the stools. These worms abound in the 
large intestine, from which as the eggs mature the parasite wanders to 
the rectum, discharges its eggs, and often passes out of the anus, in 
the vicinity of which eggs may be found. The pin-worm is one of the 
commonest of the intestinal parasites, and has been found at all ages, 
even in an infant of five weeks, though most frequently observed in 
children. The eggs are small enough to be blown about when dry, and 



DISEASES DUE TO ANIMAL PARASITES. 



339 



are offcenest swallowed in the summer, probably with fruit or vegeta- 
bles, since soaking in water destroys them. Persons of uncleanly habits 
may easily infect themselves, since eggs have frequently been found in the 
vicinity of the anus and beneath the finger-nails. The especial symptom 
is itching at the anus after the patient goes to bed, due to the movements 
of the female worm in the rectum. The annoyance is worse immediately 
after defecation : the persistent discomfort disturbs sleep, and in sensi- 
tive children may cause convulsions. The local irritation may serve as 
a cause of masturbation, and the parasite may wander into the vagina 
and occasion itching and leucorrhcea. The worm has also been found in 
the bladder, stomach, oesophagus, and mouth. In nervous persons the 
suffering is so considerable and sleep so disturbed that the patient may 
lose flesh and strength and become ansemic. 

The diagnosis is easily made by the discovery of the worms in the 
faeces, in which they may be found in masses entangled in the slime, 
or they may be seen on eversion of the anus, which is reddened and 
excoriated, or may be expelled in numbers after the use of an enema. 

Treatment. — There is no use in the administration of medicines by 
the mouth for the destruction of seat- worms. They must be reached 
by injections into the rectum and the lower colon ; saturated solution of 
salt will sometimes do the work, but the most effective and harmless 
remedy is the decoction of quassia, made by boiling two quarts of water 
with two ounces of quassia chips to a quart in an earthen vessel. A 
large salt-water injection is to be given so as to empty the lower colon, 
and, after it has come away, the whole or a part of the quassia decoc- 
tion, according to the age of the patient, is to be injected into the upper 
rectum. If it does not come away in fifteen minutes, saturated salt solu- 
tion or other irritant injection should be used. 

The Mistrongylus gigas, of which the female may be three feet long 
and the male one foot long, found in the renal pelvis and ureters of 
many animals, has in rare instances been found in the urinary tract of 
man. 

The Strongylus longivaginatus has been found in the lungs of a child, 
and may prove a possible cause of inflammation of the lung. 

AnJcylostoma duodenale. — This parasite forms a white thread-like worm, 
the females being some fifteen millimetres in length, the males perhaps 
one-third shorter, and produces the disease ankylostomiasis or dochmiasis. 
The eggs are produced in great abundance, rapidly ripen under favor- 
able conditions, and are six-hundredths of a millimetre long and four- 
hundredths of a millimetre broad. The embryo escapes, becomes encap- 
sulated, and is set free from the capsule when swallowed by the host. 
The parasite lives in the upper part of the small intestine, especially 
between the folds of mucous membrane, to which it clings by hooklets, 
and which becomes thickened and pigmented from numerous hemor- 
rhages. In fatal cases the lesions are those found in extreme anaemia. 



340 



GENERAL DISEASES. 



This parasite was recognized by Bilharz and Griesinger as the cause of 
the severe Egyptian chlorosis, and Wucherer found it to occasion tropi- 
cal chlorosis in Brazil. Its presence has been recognized in India and 
Japan, and also in the southern United States. It had been considered 
to produce the anaemia among workers in brick-yards in Italy, and it 
proved to be the source of the extreme anaemia affecting the Italians 
working in the St. Gothard tunnel. It is also recognized as the im- 
portant factor in the etiology of anaemia among workers in tunnels, 
mines, and brick-yards elsewhere, the infection probably taking place 
from the presence of embryos in the drinking-water. The severity of 
the symptoms depends upon the number of parasites present, and the 
disturbances begin with the moving about of the worms. Loss of appe- 
tite, nausea, vomiting, or abdominal pain may be present. The more 
serious derangements are dependent upon the progress of the anaemia 
due to the withdrawal of blood by the parasites. This is sometimes 
extremely rapid, and is manifested by pallor, debility, vertigo, palpi- 
tation, and eventually oedema and loss of flesh. The anaemic symptoms 
become more extreme, and the patient presents the features of a per- 
nicious anaemia. 

The diagnosis is based upon the discovery of the eggs in the faeces, in 
which they may be found in the course of six weeks after the invasion of 
the parasite. Although the disease may rapidly prove fatal, it may also 
be continued for a period of years, for the life of the parasite may be 
prolonged for five years or more. Recovery may follow its death in case 
a new infection is prevented, or a condition of more or less permanent 
invalidism may result from the complicating chronic diarrhoea or dilated 
heart. 

Ankylostoma responds to anthelmintics as do other intestinal para- 
sites. Sufficient preparation should be made to see that the duodenum 
is free from contents. Among the anthelmintics the oleoresin of male 
fern is probably the most efficient. It must be given in large doses, and 
followed after a time by a brisk cathartic, such as castor oil with oil of 
turpentine. Federici asserts that thymol is especially poisonous to the 
worm ; it must be used in large repeated doses, five grains every two 
hours, until twenty grains are taken, when a mixture of castor oil and 
turpentine can be given. 

Trichocephalus dispar. — This worm, the whip -worm, is from four to 
five centimetres long, lives in the caecum, usually in small numbers, 
although hundreds have been found, and is of frequent occurrence in 
many countries, especially in Syria and Egypt. Its pathological impor- 
tance is still in question. 

Filaria medinensis. — This parasite, the Guinea- worm, of which only 
the female is known, is some two feet long, very elastic, and prevails in 
Guinea, Egypt, and India. According to Osier, two cases have arisen 
in the United States. The disease produced by the presence of this 



DISEASES DUE TO ANIMAL PARASITES. 



341 



parasite in man is called dracontiasis. Usually a single parasite is pres- 
ent, but ten or twelve have been found. The embryos are known to enter 
a small crustacean, in which they undergo further changes, and it is sus- 
pected that this intermediate host is swallowed by man. The usual local- 
ization of the parasite in the neighborhood of the feet suggests, how- 
ever, that the worm may invade the skin. As the result of its presence, 
a circumscribed, red, painful swelling of the skin arises, in which the 
convoluted worm may be felt. Ulceration and suppuration occur, and 
the parasite is sometimes discharged, after which the abscess quickly 
heals. Unsuccessful attempts at removal result in tearing off a por- 
tion of the worm, # the remainder of which returns to the subcutaneous 
tissue and causes a continuance of the inflammation, and numerous em- 
bryos appear in the pus. The usual method of removing the worm is 
to roll the projecting end around a piece of wood, as a match, and to 
wind two or three times daily the slack portion of the worm. 

Filaria sanguinis hominis. — This worm, found by Lewis in a blood- 
clot and by Bancroft in the lymphatics, was first made known by its 
embryos, which were found in the urine by Wucherer, in Bahia. The 
mature worm, which lives in the lymph- vessels, especially in those of 
the uro -genital apparatus, is hair-like, four to eight centimetres long. 
Its embryos, about one- third of a millimetre long, and of the thick- 
ness of the diameter of a red blood- corpuscle, enter the blood in large 
numbers through the lymphatics. A drop of blood has been found to 
contain a dozen or more of the rapidly moving embryos. During the 
day they are to be found with difficulty, although readily seen at night ; 
but this periodicity may be reversed when the host sleeps by day and 
works by night. According to Manson, the mosquito is the interme- 
diate host, for he has found the embryos in mosquitoes which have 
taken blood from a patient with filarise, and considers it probable that 
the embryos of the latter are set free by the death of the insect after 
its eggs are deposited in water. The presence of the mature parasite 
in the lymphatics becomes known by the production of either hamia- 
tochyluria or elephantiasis, although it is to be recognized that these 
affections may exist independently of the presence of the filaria. In 
hcematochyluria the urine from time to time is of a milky white or pink 
color, according to the quantity of blood present, and a cream-like layer 
forms when the fluid stands for some time. The milk-like appearance is 
due to the presence of molecular fat-drops, and filarial embryos have 
been found in the chylous urine, but are more likely to be seen on exam- 
ination of the blood at night. Intermitting haematochyluria may exist 
for years with little or no general disturbance. At times it may be asso- 
ciated with pain in the region of the kidneys and with painful micturition 
from the passage of fibrinous clots. 

The presence of the mature filaria in the lymph-vessels causes the 
series of changes occurring in elephantiasis and lymph-scrotum. The 



342 



GENERAL DISEASES. 



wall of the lymphatic is inflamed, the flow of lymph is obstructed, 
the smaller lymph- vessels become dilated and varicose, and the fibrous 
tissue is thickened and oedematous. In lyniph-scrotuni a chylous fluid 
may also be present in the tunica vaginalis, and hasmatochyluria may 
be present or absent. Embryos have been found in the milky fluid 
escaping from dilated superficial lymphatics, but, according to Manson, 
are not readily seen in the blood in elephantiasis, from the obstruction 
to their passage through the lymphatics caused by the presence of the 
mature worm. 

~No treatment has been found efficacious in destroying the filaria. 

Other filarise, of less consequence, are the Filaria Loa, which has been 
found in the subconjunctival tissue of persons in West Africa and South 
America, the Filaria lentis, present in cataract, the Filaria bro?ichialis y 
observed in the bronchial glands, and the Filaria labialis, discovered in 
the lip. 

TRICHINOSIS. 

Etiology. — The calcified capsule of the trichina spiralis was seen by 
Hilton in 1832 in the muscle of a corpse. The worm was soon after dis- 
covered by Paget and described by Owen, and later was found by Leidy 
in swine : its pathogenic importance in producing the disease trichinosis 
was first definitely recognized by Von Zenker in 1860. In a week after 
its entrance into the alimentary canal of its host the embryonic trichina 
matures into a female from two to four millimetres long, or into a some- 
what shorter male, and begins to develop embryos, which continue to be 
produced for nearly six weeks to the number of fifteen hundred from 
a single female. (Leuckart.) Some of the embryos perforate the wall of 
the intestine, and entering the subperitoneal tissue are carried along the 
mesentery towards the muscles in front of the spine, so that they have 
been found both in the lymph-glands and in the blood-vessels. Others 
pass though the peritoneum into its cavity, whence they invade the 
neighboring muscles and wander into other serous cavities. When the 
embryo reaches the muscle it enters" the primitive fibre, in which in 
a few days it forms a spiral and in the course of a fortnight becomes 
encapsulated within the thickened sarcolemma. In man, in about six 
months the deposition of lime salts takes place in the capsule, and the 
presence of the muscle-trichina becomes evident by a white speck perhaps 
one millimetre long. In swine, on the contrary, calcification of the cap- 
sule is less likely to occur : hence in them the presence of the muscle- 
trichina is to be recognized only with the microscope. The encapsu- 
lated trichina thus calcified may retain its vitality for twenty-five years, 
and may live for months after the death of the host. When flesh con- 
taining the live muscle-trichinae, of which there may be millions in a 
single animal, is eaten by man, swine, rats, cats, rabbits, or guinea-pigs, 
the larvse are set free. 

The disease trichinosis comprises the disturbances resulting from the 



DISEASES DUE TO ANIMAL PARASITES. 



343 



migration of the embryos, and is found in those countries in which pork, 
especially insufficiently cooked or preserved, forms an important article 
of diet : hence it is common in Northern Germany and in other parts 
of Europe, in North and South America, in India, China, Africa, and 
Australia. According to Osier, four hundred and fifty-six cases have 
been recorded in the United States. Epidemics are frequent from the fact 
that the flesh of the infected hog is often eaten by a number of persons 
in a limited locality. 

Swine are the principal source of infection, and they are frequently 
invaded by trichinae, either from eating the infected flesh of other swine 
or from feeding on rats which have become infected from swine or from 
the contamination of their food with productive intestinal trichinae. The 
trichinae abound in the diaphragm and tongue, in which they are readily 
found with the low power of the microscope, — most conveniently when 
a bit of the muscle is compressed between glass plates. In Prussia, 
where a careful search for trichinae is made in slaughtered hogs, accord- 
ing to Eulenberg' s figures the proportion of trichinous hogs to those free 
from trichinae was 1 in 2160 in 1876, and 1 in 1817 in 1889. Ac- 
cording to Billings, of 8773 American swine examined between 1879 and 
1881, 1 in 25 was found to contain trichinae, although in a series of some 
2000 last examined the proportion was 1 to 44. The latter ratio was con- 
firmed by Salmon in 1884, who estimated the percentage of American 
trichinous swine as two and seven-tenths. Despite this large proportion 
of infected swine in the United States, epidemics of trichinosis are 
comparatively rare, due in part to the more thorough cooking of the 
flesh, in part to the destruction of the muscle- trichinae by salting the 
pork and smoking the hams and bacon. According to Yirchow, the 
rare cases of trichinosis in Germany asserted to be derived from im- 
ported American swine products are not reported with sufficient accu- 
racy to warrant this assertion. In Germany trichinae are found in man 
in about one per cent, of all autopsies. In the United States trichinous 
subjects are occasionally seen in dissecting-rooms, and more rarely at 
autopsies. 

In the early stages of the disease the mucous membrane of the intes- 
tine is injected and Peyer's patches and the mesenteric glands may be 
swollen. The muscles show various shades of color between a reddish- 
gray and a dark red. After the fifth week minute gray lines are seen, 
resulting from the granular destruction of the muscle by the trichinae, and 
with the microscope the changes characteristic of an acute myositis are 
to be found. According to Cohnheim, in cases fatal during the second 
month the liver contains abundant fat, the epithelium of the kidneys is 
often granular, at times fatty, the heart-muscle is granular, the bronchi 
contain viscid secretion, hypostatic pneumonia is frequent, and broncho- 
pneumonia patches are occasionally found. The spleen is but little 
altered. 



344 



GENERAL DISEASES. 



Symptoms. — When insufficiently cooked trichinous pork is eaten by 
man, the symptoms vary in accordance with the number of living trichinae 
introduced. When many muscle-trichinae enter the alimentary canal, the 
symptoms of an acute gastroenteritis may occur in the course of a few 
hours or after two or three days, and nausea, vomiting, diarrhoea, abdom- 
inal pain, and prostration be present. On the third or fourth day after 
eating the infected food there are chills, followed by fever 5 the tempera- 
ture reaches its maximum of 103° or 104° F. during the second week, 
the evening temperature being higher than that of the morning. The 
fever has a remittent or an intermittent type, lasts from two weeks to 
two months, its course somewhat resembling that of a mild typhoid fever, 
and is associated with loss of flesh and strength. The symptoms indica- 
tive of the entrance of the trichinae into the muscles begin during the 
middle of the second week. There is pain referred to the abdominal 
muscles and the diaphragm. The superficial muscles become resistant, 
painful, especially on motion, and tender. When the trichinae are 
abundant in the respiratory muscles there is dyspnoea, and bronchitis 
is associated ; if the muscles are attacked the patient is confined to the 
bed, and the position of the trunk and extremities is that of semiflexion. 
If the muscles of the jaw are invaded, mastication is difficult, and in- 
volvement of the tongue and of the muscles of the pharynx and larynx 
interferes with swallowing. (Edema of the eyelids and sometimes of the 
glottis, lasting for several days, accompanies the invasion of the respective 
muscles, and makes its appearance elsewhere at a later period in the 
disease. Pruritus and desquamation of the epidermis often occur as the 
oedema subsides. There is profuse sweating, which, with the fever and 
the muscular pain, has often suggested acute rheumatism. The intelli- 
gence of the patient is unaffected, except in the severest cases, but sleep 
is usually disturbed. In mild cases the symptoms are slight, and there is 
often no fever, the pains are ill defined, and muscular weakness is more 
conspicuous than muscular pain. Trichinosis in children runs a milder 
course than in adults. 

Diagnosis. — In sporadic cases the diagnosis is difficult. The con- 
tinued fever, diarrhoea, and prostration are suggestive of typhoid fever, 
but the enlarged spleen is lacking, and the muscular pain and rigidity are 
not features of the latter disease. The fever, pains aggravated on motion, 
and profuse sweating suggest acute rheumatism, but the joints are not 
swollen, and the muscles are tender to the touch, while the initial gastro- 
intestinal disturbance is lacking in acute rheumatism. Acute polymyo- 
sitis is also simulated by the muscular rigidity, pain, and tenderness, and 
the oedema of the skin. This affection is of a progressive character and 
of longer duration, and lacks the acute digestive disturbances. In the 
severe cases with conspicuous vomiting and diarrhoea, cholera or cholera 
morbus is suggested, but muscular cramps and rice-water stools are ab- 
sent. In acute poisoning by meat, fish, or milk-products, the severe 



DISEASES DUE TO ANIMAL PARASITES. 



345 



gastrointestinal symptoms of acute trichinosis are simulated, but the 
profound disturbance of the nervous system caused by these is lacking. 
Important in the diagnosis of trichinosis is its occurrence among a num- 
ber of individuals who have eaten hog-products from the same source at 
or about the same time, and in whom the continued fever, muscular pain, 
tenderness, and rigidity, oedema, dyspnoea, and wakefulness occur. The 
diagnosis is assured by the discovery of trichinae in the flesh served, and 
has sometimes been determined by their recognition in a bit of muscle 
removed from a patient for the purpose of diagnosis. 

Prognosis. — The mortality in the various epidemics of trichinosis 
varies from five per cent, to thirty per cent. , depending largely upon the 
number of trichinae in the infected meat, the method of preparation of 
the latter, and the quantity taken. Severe diarrhoea at the outset is a 
favorable sign, since it permits a considerable removal of the trichinae 
from the intestine. The more severe and general the symptoms resulting 
from the invasion of the muscles, as fever, pain, dyspnoea, the worse the 
outlook, and the longer the duration of the symptoms the more favorable 
the prognosis as to life, although complete restoration to health may not 
take place for months or even years. 

Treatment. — There is no known method of sensibly affecting the 
growth of the trichina once lodged in the human muscle : the treatment 
must be purely symptomatic and sustaining. If it should become known 
within forty-eight hours that a person has taken infected meat, the ali- 
mentary canal should be thoroughly emptied by an immediately acting 
cathartic, such as castor oil with turpentine (half a fluidounce to a 
fluidrachm), followed by quarter-grain doses of calomel every two hours 
until further purgations occur. With the calomel may be used santo- 
nin, the oleoresin of male fern, or thymol, which has been especially 
recommended by some writers. 

DISEASES DUE TO ARTHROPODES. 

Of the wingless arthropodes a number of arachnids occur as human 
parasites. The Pentastoma denticulatum is the larval form of the Penta- 
stoma tcenioides, which is found in the nostrils and communicating sinuses 
of the dog, horse, goat, and other animals, although rarely in man. The 
embryos are set free from the eggs when taken into the alimentary canal, 
and either directly or by means of the blood-current reach the nostrils, 
liver, spleen, kidneys, heart, and lungs, and become encapsulated. In 
the course of six months the Pentastoma denticulatum, four to five milli- 
metres long, is fully developed, and after two months may perforate the 
cyst wall and be evacuated. In the nostrils catarrh may be produced 
and the eggs be found in the secretion, while jaundice and digestive dis- 
turbance may follow its presence in the liver. Although in Germany 
the larval form has often been found in man, serious disturbances from 
its presence rarely occur. 



346 



GENERAL DISEASES. 



The larger Pentastoma constrictum has repeatedly been found in Egypt, 
and, according to Osier, this parasite has been ejected from the mouth 
and with the urine in America. 

The Demodex folliculorum, or acarus of the sebaceous follicles, is found 
especially in the skin of the face, but is of little pathogenic importance. 

The Sarcoptes hominis, or Acarus scabiei, the itch-insect, is visible as 
a minute white-yellowish speck. The male is twenty-three-hundredths 
of a millimetre in length by sixteen-hundredths of a millimetre in 
breadth, and the female forty-five-hundredths by thirty-five-hundredths 
of a millimetre. The latter burrows into the epidermis for a distance 
of three centimetres, lays some fifty eggs during her progress, and dies 
at the end of three months. Embryos are sufficiently developed from 
the eggs in the course of a fortnight to form fresh burrows. The itch- 
insect abounds upon the hands, especially in the interdigital folds, and 
may thence spread over the body. It is conveyed from one person to 
another, especially among those of uncleanly habits living in intimate 
relation, particularly children. The presence of the burrow is indicated 
by a small blister or papule, which in the course of a few days subsides 
and is followed by desquamation. The migration of the parasite produces 
itching, especially severe at night, and the patient seeks for relief by 
scratching, causing excoriations, hemorrhage, and exudation, and numer- 
ous punctate and linear crusts result, principally on the lower abdomen 
and the thighs, especially in the vicinity of the penis. In consequence 
of the scratching, vesicles, papules, and pustules are often present. The 
diagnosis is based upon the localization of the rash and the discovery of 
the burrows, and sometimes upon the recognition of the parasite. 

In the treatment of itch the parts should be thoroughly washed with 
a strong watery solution of soft soap, and afterwards with simple warm 
water ; following this, sulphur ointment should be well rubbed into the 
part, which should then be covered with a thick application of the oint- 
ment. This process should be repeated as often as necessary. 

Ixodes rieinus and Ixodes americanus are ticks which, though frequent 
among the lower animals, are only occasionally found on man, and pro- 
duce little or no local disturbance unless, when torn from the skin, the 
heads remain and cause a local inflammation. The treatment consists 
in picking off the tick : if the head remains it may be taken out with 
a needle. 

The Leptus irritans, or harvest-mite, a small red parasite, attaches 
itself sometimes in large numbers to the skin, and causes itching and 
papular or pustular inflammation. 

PARASITIC INSECTS. 

Of the parasitic insects the pediculus, or louse, is often found in three 
varieties, the Pediculus capitis, the Pediculus vestimentorum, and the Pedic- 
ulus pubis. They vary in size, the Pediculus vestimentorum being from two 



DISEASES DUE TO ANIMAL PARASITES. 



347 



to four millimetres long, while the pubic louse is the smallest, and is about 
one millimetre long. The head-louse lays its eggs among the hairs, to 
which they become attached and form the oval white specks known as 
nits. The bites of the insect cause itching, which is relieved by scratch- 
ing, and a serous or bloody fluid exudes. The hairs are matted together 
by the drying of the exudation, and when allowed to grow form an offen- 
sive tangled mass, the plica Polonica of the Polish Jews. The Pediculus 
vestimentorum, though living in the clothing, especially in the seams of 
those articles lying close to the skin, causes irritation by its bites, which 
are most numerous between the shoulder-blades, around the waist, and 
upon the nates ; minute hemorrhages result from the bites, and bleed- 
ing, excoriations, crusts, pustules, and ulceration are caused by the 
scratching. The long- continued harboring of the parasite results in a 
thickened, pigmented, and scarred skin, known as the vagabond's disease, 
and sometimes mistaken for the pigmented skin of Addison's disease. 
The pubic louse lays its eggs among the hairs of the symphysis pubis, 
to which they are attached as minute specks. It may also be conveyed 
to the axillary hairs, the beard, the eyelashes, and the eyebrows. The 
irritation from its bites leads to scratching, which may occasion an 
artificial eczema. The occurrence of bluish spots, taches bleudtres, upon 
the thorax, thighs, and nates, especially in typhoid fever, was attributed 
by Mourson to the migration of this parasite. Vincent Y. Bowditch has 
recently recorded his observation of these spots in a number of affections, 
and almost invariably was able to find the parasite. 

Treatment. — When a part covered with hair is infested with lice it 
is usually better to cut the hair off close, as it is almost impossible to 
kill all the nits or eggs attached to the hair. When the head is affected 
the scalp should be thickly covered over with sulphur ointment, or coal 
oil to which has been added one per cent, of carbolic acid may be freely 
used. When there are but few of the parasites in the head, saturating 
the hair with coal oil may suffice. In the case of the pubic louse, after 
removal of the hair the part may be thickly covered with mercurial 
ointment, which should be removed by thorough washing with soap and 
water in about twelve hours, and then reapplied. The mercurial oint- 
ment is also extremely efficacious against the pediculus capitis, but the 
amount necessary to be used is so large as greatly to endanger systemic 
poisoning ; we have seen an almost fatal case of salivation result from the 
free use of the ointment on the head of a vagabond. It is necessary to 
enforce thorough personal cleanliness to prevent recurrence. Whenever 
there is great irritation of the skin from these parasites the warm bath 
containing one-quarter to one-half pound of ordinary washing-soda may 
be used. A lotion composed of one ounce of alcohol, one ounce of 
glycerin, two drachms of carbolic acid, and fourteen ounces of water 
will often give relief. When lice are abundant upon the person it is 
always essential to destroy them »upon the clothing, but in the case 



348 



GENERAL DISEASES. 



of the clothing louse nothing less radical will suffice than leaving the 
clothing in a sufficiently heated oven, or boiling it thoroughly for some 
minutes in water. 

Cimex lectularius, the bedbug, four or five millimetres long, is of a 
reddish-brown color, and has an offensive odor. It lives in the joints of 
wooden bedsteads and in the cracks of the walls and floors especially of 
old buildings. At night it sucks blood from sleeping man, and produces 
an urticaria in sensitive persons. 

When there is excessive irritation the alkaline bath or the carbolic 
acid solution (see preceding page) may be used. It may be necessary 
to take apart furniture infested with bedbugs when it is not possible 
to reach thoroughly the crevices and joints. If, however, this can be 
done, the parasite can be destroyed by thorough cleanliness and the free 
application of a ten per cent, solution of corrosive sublimate. Iron bed- 
steads are always preferable. 

Pulex irritans, the flea, stings the skin, produces a minute hemorrhage, 
and may cause rose spots, petechise, or urticaria. Some persons are so 
little susceptible as not to be conscious of its presence. 

When it is impossible to avoid exposure to fleas, the free use of insect- 
powder on the inside of the stockings and other articles of underclothing 
will afford a measure of protection. 

Sarcopsylla penetrans, the sand-flea, chigoe, or jigger, is found in South 
America, in the West Indies, and on the west coast of Africa, and in- 
fests man and some of the domesticated animals. It is smaller than the 
common flea, burrows into the skin, especially between the toes and under 
the toe-nails, causes intense itching, with the formation of pustules and 
ulcers, and may lead to the loss of the toes. 

The jigger is to be removed with a minute sharp knife or a needle. 
A certain amount of protection from its attacks is said to be afforded 
by the free use of aromatic oils upon the feet. 

Myiasis. — This term is applied to the disturbances which result from 
the presence of maggots in various parts of the body. Numerous flies, 
the common house-fly, the meat-fly, the bluebottle-fly, the horse-fly, the 
carrion- fly, and the bot-fly, under favoring circumstances, lay their eggs 
from which are developed the larvae in the nostrils, cranial sinuses, audi- 
tory meatus, and vagina, and on wounded surfaces. The flies attracted by 
catarrhal conditions of the mucous membranes and neglected wounds are 
especially likely to invade the body during sleep in the open air, par- 
ticularly in the tropics. The local inflammation becomes aggravated, 
the destruction of tissue progresses, and local pain, headache, facial and 
pharyngeal oedema, and bloody discharges from the nostrils may result. 

In open wounds the larvae are to be picked off mechanically, but in 
cases of sinuses they are destroyed and removed by means of injections. 
In either case the affected part should be thoroughly cleansed and treated 
antiseptically. 



DISEASES DUE TO ANIMAL PARASITES. 



349 



Bot-flies, especially in Central America, Africa, and Russia, penetrate 
the skin and deposit their eggs, from which the larvse develop and cause 
boils, which, if numerous, produce weakness, prostration, and general 
constitutional disturbance. The eggs or larvse may be swallowed : the 
latter may live in the stomach perhaps for several days, producing diges- 
tive disturbances, especially distress, nausea, and repeated vomiting, and 
the living larvae may be found in the vomit. They may also be alive and 
present in large numbers in the intestine, giving rise to abdominal pain, 
and are later discharged with the faeces. Under such circumstances the 
patient should be freely purged by a mixture of one part of oil of turpen- 
tine and three parts of castor oil. 



350 



GENERAL DISEASES. 



CHAPTEE V. 

POISONING. 

ACUTE POISONING. 

The consideration of poisons may seem somewhat out of place in a 
treatise upon the practice of medicine, but, as poisoning may simulate 
various diseases, and as it is constantly met with by the physician, 
it has seemed to us that a brief practical consideration of the subject 
having a special regard to the clinical diagnosis and treatment may be 
of service. 

A further justification for the present chapter is found in the fact that 
the treatment of the various conditions produced by poisoning is the 
same as that of similar conditions produced by what is called disease. 
The symptoms of disease are in large part the outcome of the presence 
of poison in the blood, and so far as the treatment of the symptoms 
themselves is concerned it makes little difference whether the toxic 
agent is of such nature that the process it sets up is called " disease,' 1 
or whether it is of such character that the process is called " poisoning." 
Thus, the narcosis produced by the natural poisons of uraemia is treated 
in a similar manner to the narcosis produced by a drug. A convulsion 
caused by the action of a tetanus toxin is to be relieved in the same 
way as a convulsion caused by strychnine. 

For the purpose of diagnosis the various poisons may be divided 
into narcotics, or those poisons which chiefly affect the cerebrum, caus- 
ing narcosis ; convulsants, those which especially provoke convulsions ; 
paralyzants, those which cause wide-spread general paralysis ; cardiants, 
those which chiefly affect the circulation ; and irritants, those which 
cause violent irritation of the gastro-intestinal tract and commonly also 
of the kidneys. 

It must be remembered that many poisons act in more than one way, 
so that it is possible they should be classed under two headings. Thus, 
illuminating gas produces narcosis and also great depression of the circu- 
lation 5 whilst antimony is a violent cardiac depressant and at the same 
time a gastro-intestinal irritant. In the present chapter the poisoning is 
considered under the symptom which is the more important. The vital 
practical thought is that when a toxic substance acts in two different 
ways it is essential that two sets of remedies be employed to meet the 
two actions, the judgment of the practitioner being exercised in the 
individual case of poisoning in the decision as to which of the two sets 
of remedies shall be most actively pushed. 



POISONING. 



351 



Narcotics. 

The symptoms of narcosis are stupor deepening into coma, which 
may or may not become complete, may or may not be accompanied by 
convulsion, and may be quiet or be accompanied by delirium. Drugs of 
this class kill by acting upon the respiration, so that there is disturb- 
ance, often with slowing, of the respiration. Sometimes the respiration 
may remain normal or may even be more frequent than normal, but 
becomes extremely shallow. The character of the pulse varies greatly 
in accordance with the individual poisons. 

We shall divide the narcotic poisons into Class 1, those in which 
there is no delirium ; and Class 2 (Delirifacients), those in which the 
delirium is marked. It should be observed that in Class 1 the pupil is 
frequently contracted, sometimes normal, sometimes markedly dilated, 
and that in the deeper stages of the coma the pupillary reflexes are lost, 
though they may be preserved in the earlier part of the poisoning. In 
Class 2 the pupil is usually widely dilated and fixed. 

The most important members of Class 1 are opium, alcohol, chloral, 
chloroform, ether, illuminating gas, prussic acid, nitrobenzol, carbolic 
acid, oil of tansy, and santonin. 

Diagnosis. — In accordance with the plan of this chapter, the exist- 
ence of narcosis constitutes the starting-point in recognizing poisoning 
of the present class. Narcosis may, however, be the result of disease, 
and it is not always possible to distinguish, without a history, between a 
narcosis due to a disease and one due to a poison. Supposing that there 
is no history either of the taking of a poison or of the coming on of the 
symptoms during a disease, or, in other words, that there is no account of 
the way in which the present condition of the patient has developed, 
if there be high temperature, or highly albuminous urine, or hemiplegia, 
or strabismus, or unequal pupils, the case is almost certainly one of dis- 
ease ; although we once saw opium poisoning produce inequality of the 
pupils, and although a patient suffering from chronic kidney disease may 
have been poisoned, so that albuminuria is only a presumptive and not 
positive evidence of the existence of a uraemia. 

It must be remembered, further, that an apoplexy may come on during 
a poisoning ; indeed, its development is favored by the existence of 
alcoholism, so that sometimes patients supposed to be suffering only from 
drunkenness are found by the police dead in the cells where they have 
been put overnight. An apoplexy, however, which is sufficiently large 
to produce so complete a general relaxation as to mask the hemiplegia is 
always associated with an absolutely complete unconsciousness ; whereas 
it is rare in an ordinary poisoning for a patient to be so unconscious as to 
give no sign of life when shaken or shouted to. If a drunken person can- 
not be momentarily aroused, apoplexy should be suspected ; stertorous 
breathing under such circumstances should be considered diagnostic 



352 



GrENEEAXi DISEASES. 



of apoplexy. In advanced cases of poisoning by carbolic and prnssic 
acid, illuminating gas, or nitrobenzol, the unconsciousness may be com- 
plete. 

A malignant malarial attack may develop suddenly and closely re- 
semble a poisoning, but the disturbance of temperature should almost 
invariably lead to the recognition of the fact that the case is not one 
of poisoning: unless the patient has been lying out in the cold, a pro- 
nouncedly subnormal temperature is very rare in poisoning. High ele- 
vation of temperature probably never occurs in toxic narcosis ; certainly 
the coexistence of internal fever with a low external temperature of the 
body, such as is seen in malignant malarial attacks, does not happen in 
poisoning. 

In attempting recognition of the individual poison in any case the odor 
of the breath may point to alcohol, chloroform, or ether. Contraction 
of the pupil would indicate opium, and, unless in the later stages, would 
be associated with warmth of the surface and a slow, full pulse. Prussic 
acid can usually be recognized by the violence and rapidity of the symp- 
toms, by the furious convulsions, and by the bloody foam, the result of 
these convulsions, about the lips of the bloated, livid face ; moreover, 
death almost invariably occurs before the physician reaches the patient. 
If there be protracted unconsciousness the case is not one of prussic acid 
poisoning. Mtrobenzol poisoning can be recognized by the peculiar blue 
color of the whole surface of the body. Illuminating gas may usually 
be suspected from the surroundings of the patient ; the unconsciousness 
produced by it is extreme, and is accompanied with great depression 
of the pulse, which is rapid and feeble, and with some fall of the bodily 
temperature. 

For the purposes of treatment it is extremely important to recognize 
carbolic acid poisoning, because the antidote to this poison is so complete 
in its action. In carbolic acid poisoning, if the dose has been large the 
symptoms develop with great suddenness ; there are absolute uncon- 
sciousness, complete quiet and muscular relaxation, cardiac failure with 
rapid pulse, and a tendency to subnormal temperature ; the odor of the 
acid may sometimes be made out upon the person ; pathognomonic are 
corrugated white patches upon the lips or in the mouth, marking places 
where the strong acid has come in contact with the mucous membrane. 
In slowly developed poisoning from diluted acid, stupor, coma, muscular 
relaxation, and failing heart, with subnormal temperature, may offer no 
decisive phenomena unless there has been sufficient time for the secretion 
of the characteristic brownish or blackish urine. 

Santonin poisoning is to be recognized by the chromatopsia which 
precedes the development of the other symptoms, and by the saffron- 
colored or even purplish-red urine. According to authority, the yellow 
urine becomes red on the addition of an alkali. The convulsions are 
often violent, accompanied by opisthotonos and emprosthotonos, and are 



POISONING. 



353 



of epileptiform type. There is sometimes slight vomiting, but the symp- 
toms of gastro-intestinal irritation are never severe. 

Oil of tansy poisoning is almost always the result of an attempt to 
produce abortion. The symptoms are stupor deepening into coma, epi- 
leptiform convulsions and violent gastro-enteritis, with abortion, which 
is usually attended with much hemorrhage. The stupor and convul- 
sions distinguish this poisoning from poisonings by other ordinary aborti- 
facients. 

Treatment. — In all forms of poisoning, if there be an antidote to 
the drug it should be immediately given. Tannic acid is an imperfect 
antidote to the alkaloids and substances containing them, and should, 
therefore, be used in opium poisoning. Of the other poisons in the class, 
carbolic acid is the only ordinary one which has an antidote. This anti- 
dote is unique in that it has the capability of not only acting upon the 
poison in the alimentary canal, but also of following it into the blood 
and tissues and there neutralizing it. Whether it be late or early in the 
poisoning, the practitioner should exhibit the antidote freely, both by 
the mouth and in severe cases hypodermically. Sulphuric acid or the 
soluble sulphate should be given. Magnesium sulphate may be adminis- 
tered by the mouth, but not hypodermically, at least with any freedom, 
since when injected directly into the blood it acts as a violent poison. 
Sodium sulphate may be given hypodermically. 

If a poison has been taken by the mouth, after the administration of the 
antidote the stomach should be washed out : a brisk purgative like croton 
oil is sometimes useful for the purpose of emptying the alimentary canal. 

Unconsciousness is, from a therapeutic point of view, a matter of 
little importance : the danger in narcosis is from depression of the respi- 
ratory centres, so that the indication is to maintain respiration. In cer- 
tain cases of poisoning, notably opium poisoning, the respiratory centre 
is depressed more than are the centres of consciousness ; hence it is ad- 
visable to keep the patient awake for two purposes : first, that the de- 
pression and relaxation of sleep may not be added to the depression and 
respiratory relaxation directly due to the poison ; second, that automatic 
respiration may be reinforced by voluntary breathing. We have seen in 
opium poisoning a patient sitting breathing regularly at the word of com- 
mand when automatic breathing had practically ceased. It must be 
remembered in treating such a case that owing to the continuous lack of 
respiration there is an ever- increasing accumulation of carbonic acid in 
the blood, so that finally the narcosis is of double origin ; and if by arti- 
ficial respiration or otherwise the blood can be freed from the accumulated 
gas the narcosis is greatly lightened, and emetics and other drugs pre- 
viously powerless may become active for good. It is evidently often very 
useful to arouse a narcotized patient. For this purpose flagellations and 
other forms of rough treatment have been much employed. They are, 
however, unjustifiable. If walking or mild shaking of the patient does 

23 



354 



GENERAL DISEASES. 



not suffice, the dry wire brush should be used with a strong electrical 
current. This makes an intense irritation of the peripheral nerves with- 
out causing any inflammation or structural change. 

The drugs which are useful in overcoming respiratory paralysis are 
the so-called respiratory stimulants, — namely, atropine, strychnine, co- 
caine, and caffeine. In using these drugs it is essential to apprehend that 
they are not simple physiological antagonists to the poison, and that they 
are used for one distinct purpose. Thus, in the employment of atropine 
in opium poisoning it does not do to use the pupils as a guide to the 
amount of atropine to be given : opium contracts the pupil centrically, 
atropine dilates it peripherally, — so that the actions are not, strictly 
speaking, antagonistic. The results of the administration of the anti- 
dotal drug are to be chiefly judged by the action upon the respiration : 
if the respiration becomes sufficiently more rapid and full the desired 
result has been reached, and no more of the antidote should be ex- 
hibited until respiration begins again to fall. In order to get the neces- 
sary quick action from the antidote it should always be given hypo- 
dermically. The dose administered should be much larger than that 
used for ordinary purposes, and should be somewhat proportionate to the 
amount of the poison taken, if this be known. The remedial action of the 
antidote in such cases is in obedience to what H. 0. Wood has termed 
the " law of crossed action," a law which may be used for the purposes of 
antagonism as well as of co-action of medicines. Thus, drug x stimulates 
the heart, the respiratory centres, and the intestinal peristalsis, whilst 
drug y stimulates the respiratory centre and the motor spinal cord, but 
has no effect upon the heart. It is evident that if these two drugs are 
given at one time they will reinforce each other at the respiratory centre 
without acting together in other portions of the body, so that the greatest 
respiratory effect will be obtained with the least possible disturbance of 
other functions. We have proved experimentally that if to a dog poi- 
soned with chloral strychnine be given until general convulsions seem 
imminent, there will be a great increase in the respiratory movement, — 
an increase, however, which can be still further augmented by atropine 
or cocaine without precipitating convulsions, as would be done by further 
doses of strychnine. Hence in narcosis the best effects are to be obtained 
by using together two or more respiratory stimulants. 

In any case of narcosis in which the respiration is failing, artificial 
respiration should be resorted to. Of the ordinary methods Silvester's 
is perhaps the most effective. The patient being laid upon his back on 
a hard table or the floor, the elbows should be forced tightly against 
the chest so as to compress it, then raised upward and outward (not 
forward) until the highest point above the head is reached, and then 
slowly replaced and the process repeated. This should be done about 
ten times a minute. Of course in any case of existing deep narcosis the 
tongue should be well drawn out and prevented from slipping back upon 



POISONING. 



355 



the larynx. Yery frequently it suffices to draw the whole lower jaw 
upward and forward by the fingers inserted behind its angle. 

Yery much more effective than artificial respiration in the treatment 
of narcosis is forced respiration, in which by means of bellows or other 
power air is driven into the lungs. For the details of apparatus and 
method the reader is referred to H. C. Wood's " Therapeutics." In a 
number of cases of violent narcotic poisoning life has been saved by 
forced respiration kept up for many hours. 

In many cases of narcotic poisoning other symptoms than those of 
narcotism are sufficiently prominent to need treatment, as heart-failure 
in carbolic acid, vomiting and purging in poisoning with oil of tansy, 
etc. The treatment of these symptoms will be found under the head of 
their respective divisions. 

Delirifacients. — The ordinary poisons representing the second class 
of narcotics — i.e.j those which produce delirium with the early stage of 
the narcosis — are atropine and hyoscyamine and the vegetables which 
contain them, — such as belladonna, hyoscyamus, datura, or Jamestown 
("jhnson") weed, — cannabis indica, hyoscine, and cocaine. With the 
exception of hyoscine, these substances are all respiratory stimulants, 
and in the early stages of the poisoning increase the rate and force of 
the respiration. There appears to be no recorded death from cannabis 
indica, or Indian hemp, nor from hyoscine, though the latter drug is cer- 
tainly capable of taking life. 

Diagnosis. — All these drugs produce dilated pupils, a peculiar talk- 
ative delirium, dry mouth, usually nervous excitement and unrest, the 
whole ending, if the dose has been sufficient, in narcosis of a quiet type, 
with failure of respiration. The diagnosis between them can be made by 
noting that atropine and hyoscyamine cause a rapid, hard pulse and much 
greater excitement than is present with hyoscine, the delirium of which 
is not accompanied by muscular excitement, is talkative and muttering, 
and in its milder form simply represents a condition of simple confusion. 
Moreover, in hyoscine poisoning the pulse is near the norm in rate and 
force. Cocaine is to be recognized by the intense motor excitement which 
usually attends its action, and which may bring its poisoning into the 
convulsant group. When the dose of cocaine has been very large this 
excitement may be wanting, and collapse with unconsciouness may be 
the most prominent symptom, so that the poisoning might be placed in 
the cardiant group. 

Treatment. — In the early stage, after the use of tannic acid as an 
antidote and the evacuation of the stomach, if there be great excitement, 
morphine and even chloral may be used with caution. If the symptoms 
be due to hyoscine, the treatment should be similar to that of the quiet 
narcotic group. In the advanced stages, with stupor and quiet narcosis, 
the treatment becomes that of the quiet narcotic group, with, when there 
are symptoms of heart- failure, the use of cardiac stimulants. 



356 



GENERAL DISEASES. 



Convulsants. 

Convulsant drugs, that is, drugs the chief symptom of whose poison- 
ing is convulsions, are divided into those which produce cerebral or 
epileptiform convulsions and those which cause spinal or tetanic con- 
vulsions. The epileptiform convulsion is distinguished at once by the 
loss of consciousness, and by the fact that the convulsion is clonic. The 
spinal convulsion is without loss of consciousness, with heightened re- 
flexes, whilst the contractions are more or less persistent or tonic. 

Drugs which produce epileptiform convulsions often do so in an in- 
direct manner, as by producing anaemia of the brain through cardiac 
depression (veratrum viride, for instance). They may act directly upon 
the cerebrum, so as to cause persistent loss of consciousness. (See 
Narcotics.) The drugs which }3roduce spinal tetanic convulsions are 
cocaine and strychnine. 

Diagnosis. — In the diagnosis of strychnine poisoning it is necessary 
to differentiate it from tetanus and hysteria. Except in very rare cases, 
tetanus is at once to be distinguished by the comparative slowness of the 
symptoms, which extend over hours or days, and especially by the fact 
that the jaw is primarily locked. The masseter and other chewing 
muscles are the first to be attacked; whereas in strychnine poisoning 
they are the last. The hysterical convulsion may simulate that of 
tetanus ; there is usually, however, disorder of consciousness, which may 
be lost, or, more characteristically, may be so perverted that the patient 
seems conscious but afterwards has no memory of events which occurred 
during the convulsion, or else seems unconscious but afterwards has com- 
plete memory of such events. The hysterical convulsion is also accom- 
panied by much greater and more varied emotional disturbance than 
is the strychnic convulsion, though terror in the strychnic convulsion 
may be extreme. The reflexes, while often exaggerated in the hys- 
terical convulsion, lack the extraordinarily intense activity seen in the 
strychnic convulsion. The strychnic convulsion is more complete than 
the hysterical, involving all the muscles of the body, and producing opis- 
thotonos. The hysterical convulsion is usually more or less incomplete, 
with varieties of postures, emprosthotonos, pleurothotonos, and various 
apparently purposive attitudes, as that of the cross. In hysteria there 
is also prolonged rigidity between the convulsive attacks. 

We have seen a momentarily mistaken diagnosis made in strychnine 
poisoning, growing out of the fact that the asphyxia very rapidly de- 
veloped to the point of unconsciousness. It must be borne in mind that 
in the toxsemic epileptiform convulsion the unconsciousness precedes the 
first convulsive movement ; while in the strychnic convulsion the con- 
vulsive movement always precedes the unconsciousness, though it may 
do so only for some seconds. 

Cocaine poisoning is to be recognized by the coexistence of cerebral 



POISONING. 



357 



excitement, dilated pupil, accelerated pulse, and dry mucous membrane 
of the mouth, with convulsions which are also more partial and less 
severe than those of strychnine. 

Treatment. — In severe strychnine poisoning no attempt should ever 
be made to wash out the stomach. We have seen a fatal strychnic 
convulsion provoked by the irritation of the fauces by the stomach-tube. 
Emetics, hypodermically (apomorphine) or by the mouth, are sometimes 
helpful, but should be used only in the very beginning of the poisoning. 
Tannic acid may be given as an antidote. 

The drugs to be employed are the anaesthetics, amyl nitrite, potassium 
bromide, and chloral. Of these the two volatile substances are to be 
given usually for their immediate action, and are therefore especially to 
be employed during severe convulsions. When respiration is arrested 
by the cramp of the respiratory muscles, and no air movement takes 
place, the amyl nitrite may be given (ten minims) hypodermically, or a 
clyster of thirty to forty grains of chloral may be administered. The 
irritation, however, of the rectum by the pipe of the syringe may pro- 
duce or increase the convulsion. If the patient can swallow, the potas- 
sium bromide should be at once administered in very large doses, half an 
ounce if the strychnine has been in considerable amount, and should be 
followed or accompanied by the chloral, whose action is much quicker 
and for the moment more effective than that of the bromide. In accord- 
ance with the law of crossed action, no one drug should be relied upon ; 
but Calabar bean is too slow and uncertain in its action for practical use, 
though its alkaloid, eserine sulphate (one-twentieth of a grain), may be 
given hypodermically. In prolonged strychnine poisoning alcohol should 
be used freely, and cardiac stimulants may become necessary. 

Paralyzants. 

The poisons which cause wide-spread general paralysis may do so by a 
centric or by a peripheral action. Most of the drugs have other actions 
besides that of paralyzants, and in many cases the paralytic action is 
more or less subordinate to other influence. The most important of 
these drugs are the central motor depressants, chloral, Calabar bean, 
the nitrites, gelsemium, and the peripheral nerve paralyzants, lobelia, 
coniine, woorari, pelletierine. 

Diagnosis. — The recognition of the motor paralyzing poisons depends 
upon the existence or non-existence of symptoms other than paralysis. 
With chloral is unconsciousness ; with the nitrites are the flushed face, the 
cerebral distress and sense of distention, and the violent cardiac action, 
which in association with the extremely rapid development and fugacious- 
ness of the symptoms are characteristic ; with Calabar bean there is the 
contracted pupil ; with lobelia there is violent vomiting without purging, 
with great nausea, rapid feeble pulse, and general symptoms of collapse, 
— symptoms resembling very closely those of veratrum viride poisoning j 



358 



GENERAL DISEASES. 



with gelsemium there are dilatation of the pupil, strabismus and its con- 
sequent double vision, dropping of the jaw, and depression of the circula- 
tion, shown by rapid, feeble pulse, without much vomiting ; with conium 
the symptoms are purely paralytic, without disturbance of conscious- 
ness or circulation, — namely, an ever-increasing weakness associated with 
dilatation of the pupil and paralytic squint, without dropping of the 
jaw 5 with woorari and pelletierine there is simply a progressive general 
paralysis. 

Treatment. — To vegetable drugs of this class tannic acid is a more 
or less imperfect antidote. For the mineral drugs there is no known 
antidote. Washing out of the stomach should be practised, unless the 
patient be in articulo mortis. Death occurs through failure of respiration. 
The centric paralyzing drugs act directly upon the respiratory centres, so 
that the treatment of their poisonings is that for narcotism, except so far 
as the narcotic treatment is directed towards keeping the patient awake. 
What was said of the use of respiratory stimulants and artificial respira- 
tion under the head of Narcotics holds for drugs of the present class. 
When the paralysis and the respiratory failure are due to an influence 
upon the peripheral' nerves, centric respiratory stimulants are of very 
little value, and there are no known drugs which act antagonistically to 
poisons that affect the nerve-trunks. Artificial or forced respiration is, 
of course, indicated. 

Cardiants. 

Drugs may arrest the heart's action in systole or in diastole. Practi- 
cally, systolic arrest of the heart from a poison is almost never seen ; in 
the rare cases in which it may be threatened from overdoses of digitalis, 
aconite or some other cardiac depressant should be carefully used. The 
ordinary poisons which produce arrest of the heart's action in diastole 
are veratrum viride, aconite, the nitrites, and tartar emetic. Of these 
drugs, tartar emetic will be spoken of under the heading of Irritants, 
whilst the nitrites have already been discussed under the heading of 
Paralyzants. 

Diagnosis. — Yeratrum viride poisoning is to be recognized by the 
excessive vomiting and prostration, without either purging, pain, or dis- 
turbance of the pupil or of consciousness ; there are, in a word, no other 
symptoms, except progressive weakness, rapid pulse, subnormal tempera- 
ture, free sweating, and collapse. Aconite poisoning is characterized by 
the tingling and numbness, which usually appear first in the lips (the 
point of contact with the drug), then in the fingers and hands, and finally 
in the legs. Even without this subjective symptom, which must be told 
by the patient, aconite poison may be recognized by the coexistence of 
progressive muscular failure and loss of reflexes, with symptoms of col- 
lapse, without vomiting, purging, or other phenomenon. 

Treatment. — In the treatment of the failure of circulation produced 
by poisons, the patient should be placed upon the back in a horizontal 



POISONING. 



359 



position, or with the head slightly lower than the feet, and in case of 
sudden and complete failure of the heart should be momentarily inverted. 
As has been shown experimentally upon dogs by H. C. Wood, such in- 
version does good, not, as was formerly taught, by supplying blood to the 
respiratory centres, but by causing a flow of blood from the abdomen into 
the right heart, with consequent distention of the ventricle and mechanical 
excitement of the viscus to renewed action. It is evident that a better 
result is to be obtained by putting the patient back into the nearly hori- 
zontal position after the heart has been started, with subsequent inversion 
for a moment if it be found necessary, than by keeping the patient in- 
verted for a length of time ; otherwise the strain on the weakened left 
heart to force the blood into the abdomen and lower extremities may be 
too much for it. The sudden assumption of the sitting or erect posture 
by such a patient may, by causing sudden emptiness of the right auricle 
and ventricle, lead to immediate cardiac arrest. Absolute quiet must be 
enforced. If, as is often the case, the temperature falls, it is essential to 
maintain it, sometimes by immersion in the hot bath or by a device which 
we have found very useful in various cases of surgical and medical shock 
or collapse. An ordinary water-bed is about two -thirds filled with water 
at a temperature of 170° F., and the patient is laid upon a blanket or 
blankets on the bed ; the body is in this way half enveloped in hot water, 
and must be heated. Such a bed about two-thirds full of water will re- 
main hot from six to ten or even more hours. 

The drugs useful in cases of cardiac collapse are digitalis, strychnine, 
cocaine, and atropine. They should always be used hypodermically in 
doses proportionate to the amount of poison which has been taken. All 
that has been said of the value of crossed action in a previous section is 
equally applicable to drugs of this class. Ether given cautiously by the 
lungs, in moderate amount, is sometimes useful when the heart has sud- 
denly given out. Alcohol administered by the mouth in concentrated 
hot solution is frequently of value. The nitrites given very cautiously 
by inhalation may in sudden cases be serviceable, but it must be remem- 
bered that the slightest overdose of the nitrite converts it into a cardiac 
depressant. 

In most cases of collapse vaso- motor depression is a very important 
part of the condition. Digitalis, strychnine, atropine, and cocaine are 
all vaso -motor stimulants. They are also respiratory stimulants, and 
usually there is in the condition under discussion respiratory depression. 
These drugs are, therefore, much more effective and much more valu- 
able than alcohol or the nitrites. The nitrites are very powerful blood- 
vessel paralyzants, and must be used with the greatest caution, if at all. 
Alcohol, even in small dose, probably tends to widen the blood-paths, and 
certainly has such influence when given in full dose : practical experience 
is in accord with theory and experiment in showing that in surgical shock 
or other collapse with vaso-motor paralysis alcohol is of little value. 



360 



GENERAL DISEASES. 



Irritants. 

The number of substances which are capable of producing serious 
and even fatal gastro-intestinal inflammation is so great that it is not 
worth while to attempt in this place to give a list of them. Under 
the head of diagnosis some of the more important will be especially 
spoken of. 

Diagnosis. — The symptoms of gastro-intestinal irritation are vomit- 
ing and purging, with pain, tenderness, and secondary collapse. There 
are certain irritating substances, especially the corrosive chemicals, such 
as the mineral acids, which produce, when taken internally in concen- 
trated form and large amount, immediate fatal collapse without pro- 
nounced local symptoms ; after a smaller or less concentrated dose there 
may be immediate violent pain in the oesophagus and stomach, rapidly 
followed by collapse without vomiting. 

From the symptoms themselves it is not possible to diagnose between 
the effects of different mineral acids, but usually the source of the 
poisoning can be recognized by noticing the stains upon the clothing or 
about the mouth of the victim. Sulphuric acid makes a black stain j 
nitric acid, a deep yellow stain ; nitrohydro chloric and hydrochloric acids, 
a feeble yellow stain. The holes eaten in linen and other clothing by one 
of these acids are to be distinguished from holes due to burning by their 
edges being soft and pulpy, and, if at all recent, yielding an acid reaction 
with litmus paper. 

Among the vegetable acids, citric is scarcely capable of taking life, 
though it may produce violent vomiting and much pain. Tartaric acid 
has in a few recorded cases caused death, the primary symptoms being 
chiefly gastric. Oxalic acid causes violent vomiting and purging (often 
bloody), with stupor or even deep narcosis, and wide-spread general 
paralysis, sometimes with epileptiform convulsions, these nervous symp- 
toms occurring early and being out of proportion to the local symptoms 
because they are not dependent upon the gastro-intestinal inflammation, 
but are due to a direct action of the poison upon the nerve-centres. 
After death oxalic acid poisoning can be recognized by the presence of 
crystalline oxalates in the secreting structure of the kidneys. 

Among the mineral poisons, antimony and arsenic produce profuse 
serous stools, with an association of other symptoms, indistinguishable 
from the symptoms of true cholera or of cholera nostras. It is rare for 
acute antimonial poisoning to depart from the type, but in arsenical 
poisoning stupor and other evidences of centric nerve oppression are not 
uncommon. There is no way of distinguishing these poisonings from 
choleraic diseases except by a knowledge of the history of the case or by 
the recognition of the poison in the vomit, stools, urine, or tissues. In 
many cases extraneous circumstances may lead the physician to a work- 
ing diagnosis. Corrosive sublimate in excess produces a very violent 



POISONING. 



361 



poisoning, which is characterized by excessive abdominal pain, with 
violent vomiting and purging, the stools being small, mucous, bloody, 
and passed with much straining. 

The majority of soluble metallic salts are irritant poisons. Cupric 
sulphate can often be recognized by the blue color of the first vomit. 
With plumbic acetate the first vomit is often white and curdy (lead chlo- 
ride) ; the stools, which may be loose or hard, are always of an intense 
black color (lead sulphide). Phosphorus, which may be classed among 
the irritant poisons, is almost unique among known poisons in not 
producing distinct symptoms for from six to twelve hours after its inges- 
tion, even although it has been taken in great excess ; the symptoms and 
lesions which it causes so exactly simulate those of acute yellow atrophy 
that the poisoning can scarcely be distinguished from the natural disease, 
either during life or upon the post-mortem table, except by chemical 
examination or a knowledge of the poison having been taken. Phospho- 
rescence in the vomit or stools would be direct evidence of poisoning. 
According to M. Poulet, phosphorus poisoning can be at once recognized 
by heating the urine with nitric acid to calcination, when as dryness is 
reached there is a sudden outburst of flame. In rare cases phosphorus 
poisoning has differed from the type, with many irregular symptoms. 

Among the other irritant, poisonous drugs the only ones which we 
shall notice are oil of rue and oil of savin, which have frequently, when 
taken for the purpose of producing abortion, caused violent gastroente- 
ritis, with vomiting and purging, and abortion attended with much hem- 
orrhage, ending in death, and Spanish fly, or cantharides, the symptoms 
of whose poisoning are furious gastro-enteritis with intense pain and in- 
cessantly repeated small bloody mucous stools, accompanied by inflam- 
mation of the genito -urinary tract, as shown by violent pain, strangury, 
albuminous or suppressed urine, priapism, and finally, perhaps, sloughing 
of the parts. 

Treatment. — The antidotes to the mineral and vegetable acids, other 
than oxalic, are the alkalies and their carbonates and substances contain- 
ing them, such as soap. For oxalic acid use lime or chalk ; for antimony, 
tannic acid ; for arsenic, freshly precipitated ferric hydrate, which may 
be made by precipitating solution of tersulphate or subsulphate of iron, 
or tincture of ferric chloride, with an alkali, preferably magnesia (ferri 
oxidum hydratum cum magnesia, U.S.'). The antidotes to plumbic ace- 
tate are a soluble sulphate or chloride, such as common salt, or an alkali 
or its carbonate, and soap. To almost all irritant metallic salts the anti- 
dote is soap or an alkali ; to corrosive sublimate, white of eggs ; to 
phosphorus, cupric sulphate or potassium permanganate. 

The drugs to be used in toxic gastro-enteritis are opium, — which in 
very severe cases threatening immediate collapse may be first given 
hypodermically, but which it is usual preferably to exhibit by the rec- 
tum, — bismuth, and chalk. Demulcent liquids should be used freely, 



362 



GENERAL DISEASES. 



especially when there is great irritation of the kidneys. Leeching at 
the epigastrium, and sinapisms or turpentine stupes over the whole 
abdomen, followed by warm, moist applications, are often of great ser- 
vice. Acute toxic nephritis is to be treated in the same manner as the 
same disease from natural causes. 

Among the irritant poisonings may be mentioned the cases in which 
violent symptoms and even death have been produced by the taking of 
various articles of food which have undergone changes allied to putre- 
faction. Among the foods which have produced serious results may be 
mentioned European mussels, fish, sausage, ham, various fresh meats, 
canned goods, milk and its products, such as cheese, ice-cream, and cus- 
tards, or various complicated desserts, like cream-puffs. The nature of 
the poison in these cases varies to some extent, but usually it is a ptomaine, 
a nitrogenous base allied to the alkaloids, the result of putrefactive or 
fermentative changes produced by the presence of bacteria. 

The symptoms may develop directly after the ingestion of the poison- 
ous food, or may be delayed for some hours. They usually consist of 
violent vomiting and purging, accompanied by abdominal uneasiness and 
sometimes great pain. In rare cases there is constipation. With these 
abdominal symptoms are often associated nervous disturbances out of 
proportion to the gastro -intestinal irritation, and evidently directly pro- 
duced by the poison. These are vertigo, disturbances of vision, dilatation 
of the pupil, delirium, or stupor, ending, it may be, in coma and death. 
Sometimes there are violent convulsions. The disturbance of the circu- 
lation is usually marked, as shown by rapid, feeble, or irregular heart- 
action, with a small, thready, rapid pulse. The temperature may be 
subnormal or febrile. Dryness of the throat, rigors, widely distributed 
cramps, numbness and tingling in the extremities, and difficulty in 
swallowing, are not rare phenomena. 

The treatment in these cases consists, first, in emptying the alimen- 
tary canal ; secondly, in treating the symptoms as they arise. Sometimes, 
especially in children, failure of respiration is an early and very distinct 
symptom. We have seen life saved by placing such a patient in the hot 
bath and using artificial respiration until reaction set in, with vomiting 
and relief of the stomach. 

CHRONIC POISONING. 

LEAD POISONING. 

Colica pictonum, or subacute lead poisoning, is especially seen in workers 
in lead or its compounds, though it may be the result of accidental 
poisoning in those who do not work in the metal. The symptoms are 
malaise, followed by violent abdominal colicky pains, which are more or 
less constant, with exacerbations, and vary in character, being some- 
times sharp and sometimes dull, and frequently described as a twisting 



POISONING. 



363 



around the navel. There is usually no appetite, and vomiting and retch- 
ing are common. The walls of the abdomen are retracted, rigid, knotted ; 
the bowels are obstinately costive ; the tongue is contracted and whitish, 
the appetite absent, and the thirst sometimes excessive. Neuralgic pains 
in the thorax and in the extremities are of frequent occurrence. In some 
cases the conjunctiva is distinctly icterode. 

Lead colic may yield to treatment or by recurrent attacks may pass 
into chronic lead poisoning. 

Chronic lead poisoning varies so much as almost to baffle concise de- 
scription. The symptoms can, perhaps, best be studied by arranging 
the cases in groups $ but it must be remembered that not only do these 
groups shade into one another, but also that there are all kinds of mixed 
cases, — cases which offer simultaneously or successively symptoms of two 
or more of these various groups. 

The first group contains the great bulk of cases of chronic lead 
poisoning, at least as seen in this country. The symptoms consist of 
failure of health, more or less digestive disturbance, and double wrist- 
drop, — i.e., paralysis of the extensor muscles of each hand. Not rarely 
the only noticeable symptom is the wrist- drop, the general health seem- 
ing to be good. The true nature of such cases can usually be at once 
recognized by the bilateral character of the extensor-paralysis, cerebral 
and pressure paralyses being almost invariably unilateral. We have 
seen, however, bilateral pressure palsy, and also unilateral plumbic 
wrist-drop, due to a local absorption of lead, in an artisan whose hand 
was much of the time in a preparation of the metal. The wrist-drop 
may exist alone, but not rarely there is with it anaesthesia of the affected 
part, or sometimes of the shoulders or other unparalyzed portion of the 
body. When the paralysis is complete, the electro-contractility of the 
muscles is in great part or altogether absent. 

The rarer forms of chronic lead poisoning may be divided into the 
cerebral, the periphero-spinal, and the nutritive. 

In the cerebral cases should be included those which are commonly 
spoken of as encephalopathia saturnina, or saturnine cerebritis, in which the 
violent brain-symptoms may develop with great suddenness, or may be 
preceded by headache, giddiness, sleeplessness, disturbed vision, strabis- 
mus, tinnitus aurium, psychical aberration, or other prodromes of cere- 
bral disturbance. Delirium, which is among the chief manifestations of 
the fully formed condition, may be mild, but is often maniacal ; stupor 
may replace it or alternate with it; and violent epileptiform convul- 
sions, ending in coma, are not infrequent. These convulsions are usually 
the precursors of death, but recovery may occur. 

Without the development of such severe symptoms, headache, loss 
of memory, giddiness, somnolence, hemianesthesia, disturbance of the 
special senses, aphasia, monoplegia, hemiplegia, or multiple cerebral 
palsies may occur during chronic lead poisoning. Death, preceded by 



364 



GENERAL DISEASES. 



severe cerebral symptoms, may take place without organic lesion ; but 
usually, when focal symptoms have been present, localized alteration of 
brain structure, secondary to diseases of the cerebral vessels, or to chronic 
inflammation of the brain or its membranes, can be detected. Sometimes 
the cerebral symptoms are ursemic ; indeed, true plumbic encephalopathy 
and plumbic ursemia from contracted kidney may coexist. Again, the 
more serious affection may be masked by a saturnine hysteria, since 
cases have been reported by Charcot and by Dutilh in which hysterical 
hemianesthesia, amaurosis, anosmia, loss of sense of taste, and other 
cerebral symptoms have been the outcome of a major hysteria due to 
chronic lead poisoning. Such cases as these probably occur only in indi- 
viduals of hysterical temperament, and must be extremely rare in persons 
not of the so-called Latin peoples. 

Disturbances of vision are so frequent and so marked in lead poi- 
soning as to deserve special mention. The amblyopia may come on 
slowly or suddenly ; it may be partial or complete ; it may coexist with 
kidney disease or may be entirely independent of the latter ; associated 
with it may be a true optic neuritis or a true optic atrophy, but, on the 
other hand, it may exist without demonstrable disease of the optic nerves. 
It is undoubtedly often due to a disease of the optic nerves themselves, 
but the occurrence of homonymous hemianopsia in some cases seems to 
demonstrate that the blindness may be of centric origin. Strabismus 
from paralysis of the external rectus or other ocular muscle is sometimes 
of saturnine origin. 

The second group of cases of chronic lead poisoning comprises those 
in which the nerve-symptoms apparently originate below the cerebrum. 
Among these may be mentioned cases such as have been reported by 
Putnam, by Tissier, by Eaymond, and by G. L. Walton, in which the 
phenomena resemble those of locomotor ataxia, except in the presence of 
tenderness over the nerve-trunks, preservation of the tendon reflexes, or 
some other atypical symptoms. We have seen cases in which the symp- 
toms simulated those of an acute poliomyelitis, consisting chiefly of wide- 
spread paralyses with rapid wasting of the muscles. These cases usually 
can be differentiated by the presence of violent neuralgic pains, paralysis 
of the bladder and rectum, or other atypical symptoms. Again, cases 
very closely resembling ascending or Landry's paralysis have been re- 
ported. Severe intractable chorea has been produced by lead. Dis- 
turbances of sensation may occur in lead poisoning ; anaesthesias are not 
very rare, and violent neuralgic pains, probably due to neuritis, may be 
the chief manifestation. In one case under our care the symptoms were 
intense general pruritus, with violent neuralgic pains shooting through 
the rectum and the urethra, coming on at night and producing an in- 
somnia which appeared to be unconquerable. The lesion in most of 
these motor and sensory cases is probably in the nerve-trunks, and the 
very rapid pulse seen in some of them may be due to disease of the vagi, 



POISONING. 



365 



since Prevost and Binet have found pronounced degeneration of these 
nerves. 

The third group of cases contains those in which the poison chiefly 
expends itself upon glandular or visceral organs or in producing wide- 
spread nutritive changes. It would seem that almost any of the vital 
structures may undergo degeneration. Potain reports saturnine cirrhosis 
of the liver ; Valence details a plumbic parotitis. Eudolph Maier has 
found in poisoned animals atrophic degenerations of the intestinal glands 
and walls ; and there can be no doubt that similar alterations sometimes 
aid in the production of emaciation and ansemia in human plumbism. 

Temporary albuminuria may occur in lead poisoning without serious 
implication of the kidneys ; while, on the other hand, fatal nephritis 
may exist when there is no albumin in the urine. A persistent low 
specific gravity of the urine in lead poisoning is a symptom of the utmost 
gravity. Geppert confirms the observation, previously made by Oliver, 
that in temporary plumbic albuminuria many isolated kidney epithelial 
cells may often be found in the urinary sediments : and it is evident that 
a persistence of this condition must end in chronic renal disease. After 
death, which may be induced by urseniia, the kidneys are found con- 
tracted, granular, with excessive development of the fibrous tissue (fol- 
lowed by contraction) and great thickening of the walls of the blood- 
vessels : these changes are identical with those of contracted kidney 
produced by gouty and other irritant poisons. As Ellenberger and Hof- 
meister have shown that the lead is chiefly eliminated by the kidneys, 
the frequency of plumbic nephritis is easily explained ; but it is not 
readily perceived why it is so frequently associated with an arthralgia 
whose course and lesions closely simulate those of chronic gout. 

There are cases of lead poisoning which do not conform to any of 
the types as yet given. Acute asthma has been produced by the in- 
halation of the dust of white lead, whilst chronic saturnine asthma 
occurs in feeble, narrow-chested people. James J. Putnam asserts that 
in lead poisoning of children the legs and feet are commonly paralyzed. 
Pagliano has reported saturnine facial palsy. Upon pregnant women 
the influence of the poison is very deleterious, and, as was shown by 
Constant] ne Paul, it often produces the early death of the foetus. 

In those cases of lead poisoning which pursue a slow course to death, 
the paralysis involves after a time the extensors of the lower as well as 
of the upper extremities, epileptic paroxysms occur at intervals, racking 
pains shoot through the limbs, points of cutaneous anaesthesia appear, 
and often albuminuria aids in producing the fatal issue. Gradually 
the patient becomes more and more cachectic, general oedema and the 
whitened skin betray the increasing anaemia, the paralysis extends from 
muscle to muscle, locomotion becomes impossible, and, if a convulsion 
or other accident do not close the scene, death at last takes place from 
loss of power in the respiratory muscles. Malassez has found that in 



366 



GENERAL DISEASES. 



the anaemia of lead poisoning the red globules are not only diminished 
in number but also increased in size. After death the metal has been 
detected in all the soft and hard tissues of the body. 

Diagnosis. — The diagnosis of lead poisoning is easy when the char- 
acteristic blue line upon the gums where they join the teeth is present, 
but death may occur without any such mark of plumbism ; in which case, 
if the symptoms be irregular, the nature of the attack can be made posi- 
tive only by an examination of the urine. Before this is done potassium 
iodide should be given in moderate doses for four or five days, so as to 
insure the elimination of lead if it be in the system. The urine should 
be slightly acidified and put in flint-glass bottles immediately after it 
is passed, and at least one quart of it should be sent to the chemist. 

Treatment. — In the treatment of chronic lead poisoning there are 
three indications : first, to prevent the ingestion of more of the poison j 
second, to aid in the elimination of that in the system ; third, to relieve 
symptoms and restore lost functions. In lead colic both of the last two 
indications are met by purgatives, to which opium should be added 
to relieve pain. It is often necessary to use the most powerful drastics, 
such as croton oil ; but senna, salts, and other of the milder cathartics 
should always be tried first. Alum, it is asserted, acts in some unknown 
way as a specific in lead colic, and from twenty to sixty grains of it may 
be given four or five times a day ; but our experience is not favorable to 
its use. In chronic lead poisoning, to fulfil the second indication baths 
of potassium sulphide should be employed, and potassium iodide (five 
grains three times a day) be administered internally. Oddo and Silbert 
state that the elimination of lead through the skin in chronic lead 
poisoning is important, and is facilitated by injections of pilocarpine. 
Baths containing six to seven ounces of potassium sulphide should be 
given in a wooden tub, two or three times a week. The patient during 
the half-hour of the bath should be from time to time well rubbed with 
a coarse towel. On coming out he is to be thoroughly washed with 
warm soapsuds. When severe cerebral symptoms arise, treatment is of 
little avail, and should be largely expectant. In cases of lead poisoning 
in which the symptoms resemble those of acute poliomyelitis we have 
used ascending doses of strychnine with extraordinary results, rapidly 
deepening paralysis being almost at once controlled. It is essential that 
the strychnine be pushed to the point of systemic intolerance. It is 
best to administer it hypodermically at least three times in the twenty- 
four hours. 

The local use of electricity is exceedingly important to restore the 
lost function of nerve and muscle. When the faradic current elicits a 
response, it should be employed ; but in some cases the continued current 
retains its power after the induced current has lost all its influence. The 
rule is always to apply that current which causes contraction with the 
least pain ; if both fail, the continued current should be used, the poles 



POISONING. 



367 



being reversed at intervals of four or five seconds. The electrical seances 
should be tri- weekly, each lasting about fifteen minutes, and should be 
persevered in for months. 

ARSENICAL POISONING. 

The symptoms of chronic arsenical poisoning vary, and may be very 
obscure. They were summed up by the late Professor Taylor as follows : 
" dryness and irritation of the throat, irritation of the mucous mem- 
branes of the eyes and nostrils, dry cough, languor, headache, loss of 
appetite, nausea, colicky pains, numbness, cramp, irritability of the 
bowels, attended with mucous discharges, great prostration of strength, 
a feverish condition, and wasting of the body." The constitutional 
troubles most uniformly present in these cases are weakness and emacia- 
tion, often accompanied by more decided nervous manifestations than 
the picture drawn by Taylor would suggest : great depression of spirits 
and irritability of disposition, sleeplessness, giddiness, tinnitus aurium, 
failure of memory, cerebral neurasthenia, headache with a feeling of 
constriction in the forehead, and numbness in the extremities, are prob- 
ably the most common symptoms, although muscular tremors or stiff- 
ness, vertigo, and even convulsions and paralysis, are not extremely rare. 
Kirchgasser asserts that the most characteristic phenomena are a brown 
pigment- deposit in the skin of the face, inflammatory affection of the 
eyelids, and disturbances of sensibility and motion, which affect most 
frequently the lower extremities, together with scalding during urination. 

Diagnosis. — The diagnosis of chronic arsenical poisoning is often very 
difficult. Sometimes eruptions upon the skin, with laryngo-bronchial 
catarrh, swollen finger-joints, emaciation, and other disturbances of the 
general nutrition, constitute the main feature of the case. Peripheral 
neuritis is almost always due to the presence of some poison, and general 
emaciation without local disease and with atypical symptoms is usually 
either toxic or diathetic. In some cases the symptoms have been gastro- 
intestinal irritation, anseruia, dermatitis, redness of the conjunctiva, 
puffiness under the eyes, headache, irritation of the upper air-passages, 
albuminuria with casts and blood, and peripheral neuritis. The mere 
inability to account for failure of health should put the practitioner on 
his guard. Extraneous circumstances often are such as to suggest the 
truth. If green or other colored wall papers are in the bedroom, or 
if the patient is a chemist or a worker in arsenical compounds, aroused 
suspicion should lead to a chemical study of the urine. 

Treatment. — Eecovery almost invariably occurs in chronic arsenical 
poisoning, if the continuous intaking of the poison be arrested. There 
are no known means of increasing the elimination of the metal. The 
symptoms must be met on general principles as they arise. Gastro- 
intestinal inflammation, peripheral neuritis, and other lesions should be 
treated in the same way as though produced by more ordinary causes. 



368 



GENERAL DISEASES. 



CHRONIC ANTIMONIAL POISONING. 

Chronic accidental poisoning by antimony or its compounds is practi- 
cally unknown, but in a number of cases tartar emetic has been given 
continuously in small but accumulating doses with criminal intent. The 
symptoms produced have been those of a subacute gastro-enteritis with 
numerous exacerbations, followed by emaciation and finally death by 
exhaustion. In such a case suspicion should be aroused by the gastric 
disturbance being much more severe than that which usually accom- 
panies enteritis from natural causes, and by the unaccountable exacer- 
bations, baffling all medical foresight and treatment. There being no 
characteristic symptoms, the detection of the true nature of such a case 
must be based upon chemical examination of the excreta. As the metal 
is freely eliminated by the kidneys, and as the urine is frequently taken 
for examination by the physician in a suspicious case, this fluid could 
be chemically studied and a decision arrived at without alarm to those 
about the supposed victim. 

Chronic antimonial poisoning will almost always get well spontane- 
ously on the cessation of administration. For the relief of the symp- 
toms opium should be freely used. Strychnine and digitalis should be 
given hypodermically if respiratory and cardiac failure are alarming. 

ALCOHOLISM. 

Alcohol is an irritant narcotic, which, under certain circumstances, 
has a tendency to cause numerous degenerative changes in various organs 
and tissues of the body. The diseases produced by its abuse are in great 
part elsewhere considered in this volume. At this place the considera- 
tion will be confined, first, to the results of an ordinary Alcoholic De- 
bauch ; second, to Delirium Tremens ; third, to Alcoholic Insanity. 

ACUTE DEBAUCH. 

During an acute debauch the irritant action of the alcohol is felt at 
its point of entrance and also at its point of escape from the body. 
There are, therefore, primarily and chiefly, a toxic gastritis and an irri- 
tation of the hepatic cells, which may be so intense as to alter their 
functional activity, and there is also great renal irritation ; hence the 
icteric conjunctiva, heavily coated tongue, yellowish skin, nausea and 
vomiting, headache, gastric and hepatic tenderness, and scanty, albu- 
minous urine. The indications for treatment are to get rid of any re- 
maining alcohol, to relieve the congestion of the portal circulation and 
of the stomach, to purify the blood, to soothe the kidney, and to sup- 
port the nervous system. To meet the first of these indications, very 
free sweating may be induced by the Turkish or the vapor bath, or by a 
hypodermic injection of pilocarpine. In many cases an emetic, tartar 
emetic if the patient is robust, aided by large draughts of hot water, 



POISONING. 



369 



may be of great service in relieving the stomach and assisting the full 
dose of calomel in starting biliary secretion. Cream of tartar and other 
saline diuretics may be early used, assisted by copious draughts of hot 
water. The food should be liquid, but stimulating and nutritious : milk 
with lime water, strong broths, and beef-essence, are very useful. The 
peculiar gastritis caused by alcohol is accompanied by so much relax- 
ation and so much apathy of the mucous membrane that Cayenne pepper 
and other irritant spices are often very useful additions to the food. More- 
over, after acute symptoms have subsided, simple bitters are often of 
service ; especially are the alkaloid hydrastine and its salts of value. 

When the gastric symptoms are very severe, leeching and subse- 
quently blistering of the epigastrium may be practised. Ordinarily, no 
alcohol should be allowed, but bromides, chloral, sulphonal, and opium 
may be administered when required by the nervous symptoms. Strych- 
nine and tonics should usually be withheld until the gastro-intestinal 
irritation has been subdued. If, however, there be signs of exhaustion or 
heart-failure, it may be necessary to give both strychnine and digitalis. 

DELIRIUM TREMENS. 

Definition. — A peculiar form of confusional insanity produced by 
the excessive use of alcohol or, in rare cases, of other narcotics, charac- 
terized by the existence of tremors and an underlying condition of fear. 

Etiology. — Mania a potu often develops after the suspension of a 
bout of heavy drinking ; but the old idea that it is solely due to absti- 
nence from alcohol is not correct, as the symptoms may develop in the 
midst of a debauch, and cannot be relieved by simply supplying alcohol. 
The disease is more common in men than in women, probably because 
drinking is especially a masculine vice. 

Morbid Anatomy. — There is no recognizable lesion in delirium 
tremens. 

Symptomatology. — In the mildest form of delirium tremens, the 
" horrors" of old drunkards, the symptoms consist of insomnia, with 
restless, broken sleep, tremulous hands, extreme depression of spirits, 
pronounced irresolution, and a weak, confused mental condition, with 
frightful imaginings and vain alarms. 

The symptoms of the fully-formed disorder may appear abruptly, but 
in most cases are developed gradually out of the " horrors." The insom- 
nia, which is at first partial, becomes absolute, whilst hallucinations of 
sight or hearing, and more rarely of touch, appear. The emotional de- 
pression increases and develops into a state of perpetual fear and terror. 
The hallucinations are always tinged with sadness or horror : disgusting 
objects, such as snakes, toads, rats, mice, and other unclean creatures, 
climb about the bed or over the person ; whilst voices of threatening, 
of reproach, or of foreboding are heard. During the delirium there is 
unnatural loquacity, and often pronounced restlessness. The delirium 

24 



370 



GENERAL DISEASES. 



may at first be paroxysmal, — worse at night, better in the day,— bnt 
finally it becomes constant. The patient may pnt on an appearance of 
violence, and may even attack an attendant, always, however, because 
such attendant is the subject of his delusion, the violence being a battle 
of despairing defence and not a combat of aggression. Perhaps the most 
characteristic feature of the delirium is that which is common to most 
forms of confusional insanity, — namely, the extraordinary versatility of 
the false ideas. Tremor is usually present from the first ; it is irregular, 
and most frequent in the arms, face, and tongue, but it may attack the 
whole body, and is always increased by efforts at movement. 

In the early attacks of delirium tremens, occurring in very robust 
people, when all the mucous membranes are irritated, and when there is 
probably an irritation of the brain and its meninges by excrementitious 
materials in the blood, there may be a strong and excited pulse, but in 
the vast majority of cases the disease is plainly asthenic, with loss of 
muscular power, and with a pulse which is rapid and feeble, or, if it 
preserve an appearance of strength, very soft and compressible. The 
temperature is usually from one to three degrees above the norm: a 
record of 104° F. points strongly to the existence of some complication. 
Free sweating, scanty, albuminous urine, and complete anorexia are 
common features of the disease. 

The recovery from delirium tremens may be sudden, after a pro- 
longed sleep ; or it may be gradual, through a series of restful nights ; 
or the dreams may end in death or in chronic insanity. 

In some cases of delirium tremens the symptoms are different from 
those which have been described. The patient has apparently control of 
himself, receives his physician with a quiet, gentle courtesy, and answers 
questions without irritation ; but he is evidently preoccupied, occasion- 
ally turning his head or casting furtive glances from one side of the apart- 
ment to the other ; really, during the whole period he is seeing visions 
and hearing sounds, laboring under the profound apprehension of attack, 
watching always against the enemies of whose presence he is absolutely 
convinced. 

Complications. — Any of the various diseases of the liver, kidneys, 
or other organs, commonly produced by the excessive use of alcohol, may 
complicate delirium tremens. Acute pneumonia is very apt to develop 
early, especially in drunkards who have suffered exposure. It may come 
on without cough or pain or other symptoms save increased frequency 
of breathing and increased elevation of the temperature: hence it is 
essential for the physician to examine the chest daily in every case of 
delirium tremens. Not rarely pneumonia precedes the coming on of the 
delirium tremens, which then must be looked upon as the complication. 

Diagnosis. — The peculiar forms of the hallucinations, the underlying 
emotional condition, and the tremors make the recognition of delirium 
tremens very easy, even when there is no history of the case. 



POISONING. 



371 



When pneumonia occurs during a period of delirium tremens the type 
of the delirium may change, tremors may be lost, and the patient may 
become so violently aggressive as to lead to a mistaken diagnosis. 

Prognosis. — Death is very rare in the first attacks of delirium tre- 
mens, but, as most victims of the alcoholic habit do not reform, death is 
very frequent in recurrent attacks of the disorder. The prognosis, there- 
fore, becomes more serious with each recurring attack, is greatly increased 
in gravity by the existence of any organic disease, and is very critical 
when pneumonia develops. It usually is the result of exhaustion or 
failure of the heart's action, which may be sudden. A temperature of 
105° F. is rarely recovered from. When the delirium tremens complicates 
a severe traumatism it adds enormously to the fatality. 

Treatment. — In the treatment of delirium tremens the first indica- 
tion is for restraint to prevent injury by the patient to himself or to 
others. Freedom in a well-padded room may be allowed, but in the 
majority of cases such a room is not available, and properly constructed 
straps securing the person in bed are, in a violent case, much better than 
restraint by means of nurses, the strap exciting less antagonism than 
does an attendant, and being more steady and certain in its restraint. 
Thoroughly padded leather wristlets and anklets may be secured to the 
bed, and a loose chest strap may be employed in very violent cases. 

The second indication is for the support of the system by means of 
highly nutritious and stimulating food. Milk, strong soups or beef-essence 
with eggs stirred into them just as they have ceased boiling, and similar 
liquids, usually constitute the best articles of diet. As the digestion is 
in these cases often deranged, it is essential for the practitioner to re- 
member that the food which nourishes is not that which enters the stom- 
ach, but that which is digested : so that the effort should be by frequently 
repeated small portions of nutriment to get as much material worked 
up as possible. Often partially predigested food may be used with ad- 
vantage. Again, the mucous membrane, which has been accustomed 
to the local effects of alcohol, is often simply beneficially stimulated by 
amounts of red pepper and other spices which would produce gastritis in 
a normal stomach : hence, even though the stomach of the drunkard is 
inflamed, highly seasoned food is usually of great service. The limit of 
the amount of food given in these cases should be that of possible diges- 
tion. When the stomach will not take food freely, rectal feeding should 
be employed. 

In the medical treatment of delirium tremens the first indication is 
in most cases to relieve abdominal engorgement and to remove effete 
materials from the system. Three grains of ipecacuanha may be ex- 
hibited in pill form every fifteen minutes until free vomiting is produced, 
and, even if the patient is suffering from excessive nausea and vomiting, 
this practice is often of service. On the other hand, when great feeble- 
ness exists the use of such an emetic may be improper, and in rare, 



372 



GENERAL DISEASES. 



markedly sthenic cases veratrum viride given in drop doses of the fluid 
extract until it vomits may be advantageously substituted for the ipe- 
cacuanha. After the ipecacuanha has acted, a grain of calomel may be 
given every hour until free purgation is induced, and not rarely an 
effervescent mixture containing potassium citrate is very serviceable in 
acting as a depurant through the kidneys. Again, profuse sweating 
produced by pilocarpine or the hot bath may sometimes be useful. 

The second indication for medical treatment is to quiet nervous 
excitement. For this the bromides and hyoscine hydrobromate must be 
relied upon. These drugs should be given steadily day and night at 
regular intervals, the hyoscine being withdrawn if found in any way to 
disagree with the patient. 

The third indication is to produce sleep. For this purpose various 
hypnotics have been used. Sulphonal may be employed; paraldehyde 
has been exhibited ; but the combination of chloral and morphine sul- 
phate far exceeds in efficiency and general applicability all other hyp- 
notics. The chloral (fifteen to twenty grains) and morphine (grain 
one-quarter to one-third) may be exhibited at bedtime, and repeated in 
half-doses at intervals of an hour, pro re nata, care being exercised not 
to overdo the exhibition of narcotics. 

The fourth indication is to support the system by means of stimulants. 
One of the most important questions to be decided is as to the necessity 
of using alcoholic drinks. In many cases of delirium tremens alcohol 
does harm rather than good, and in the majority of cases its use is not 
essential. The moral reasons against its employment are very strong, 
and therefore commonly it is not wise to give it. On the other hand, in 
feeble subjects or in old alcoholics the exhibition of alcohol in some form 
or other may be necessary to the saving of life. In many cases of de- 
lirium tremens strychnine is serviceable as a stimulant, but when there 
is any fear of cardiac failure digitalis is the most reliable of all remedies. 
It must be given in very large doses, and usually enormous amounts are 
well borne. Various clinicians have claimed very good results from the 
exhibition of half- ounce doses of the tincture, but we think that a safer 
method is to give from ten to twenty minims at intervals of from two 
to four hours, watching closely the effect, and withdrawing the remedy 
as soon as any evidence of the digitalis pulse can be perceived. 

Congestion of the lungs occurring in delirium tremens may be bene- 
ficially treated by ergot in large doses (thirty grains of the extract). It 
should be at once the signal for free stimulation, and for the exhibition 
of large doses of digitalis. Camphor is used to a considerable extent on 
the Continent of Europe as a stimulant. Musk certainly has a distinct 
but transitory power ; it should be given in large doses (preferably fifteen 
grains in two ounces of emulsion with twenty minims of laudanum by 
the rectum) every six hours. Free counter- irritation by means of poul- 
tices containing mustard or by means of turpentine stupes is also ser- 



POISONING. 



373 



viceable. After from twenty-four to thirty-six hours the ergot should be 
withdrawn, and five minims of turpentine given in emulsion every two 
hours. 

ALCOHOLIC INSANITY. 

Closely allied in symptoms and probably also in basal cerebral con- 
dition to delirium tremens is the chronic alcoholic mental aberration to 
which the term alcoholic insanity is usually applied. Under the con- 
tinuing influence of alcohol the brain performs its functions slowly and 
imperfectly. The mental movements become sluggish, the memory is 
impaired, the power of fixing the attention is diminished, and the control 
of the will is almost abolished. Usually with this condition there is a 
tendency to emotional depression, and often a peculiar suspiciousness 
which is the ground- work for delusions. In such a case, if the drinking 
habit be maintained, delirium tremens may result; and this delirium 
tremens may be recovered from, or may more rarely end in a chronic 
mental aberration, — an alcoholic insanity. In another set of cases the 
alcoholic insanity is gradually developed out of the condition described 
above without the production of a distinct delirium tremens ; but even 
in this form of insanity the symptoms often resemble those of delirium 
tremens. 

The hallucinations are very numerous, constantly changing, full of 
terror and disgust, as in delirium tremens, but are less acute and give 
rise to less excitement ; in most cases they take the form of delusions of 
persecution : voices of reproach or of threatening, mocking faces, unclean 
beasts, tormenting devils, — these and similar hallucinations may drive 
the victim into a profound melancholy, ending in suicide. Very often, 
however, the mental condition in chronic alcoholic insanity is less vio- 
lent, the subject simply being full of delusions of persecution which in 
a very large proportion of the cases have a sexual coloring or relate to 
poisoning. Almost universally the mind of the husband continually runs 
upon the sexual relations of his wife, until there is a fixed, overpowering 
delusion that she is unfaithful. This delusion may in turn lead to an 
outburst of uncontrollable jealousy and rage, so that wife-murder is not 
a rare result of alcoholic mania. Usually in alcoholic mania there is a 
substratum of fear, which in itself may lead to violence, but in some 
cases the subject is aggressive. It is in such instances that the marked 
relation between the presence of alcohol in the blood and the insane out- 
burst can be seen. The maniacal drunkard may be apparently rational, 
certainly quiet and peaceable, when not under the influence of alcohol ; 
but by a moderate dose of the poison he may be converted into a wild 
beast as murderously aggressive as a tiger. This, too, may happen when 
the man is capable of walking straight and of talking rationally on gen- 
eral subjects. In many such cases honest testimony has been given that 
the subject was neither drunk nor crazy when he committed the crime, 
although in fact he was in a condition of violent alcoholic insanity. 



374 



GENERAL DISEASES. 



The form of alcoholic insanity described in the preceding paragraph 
is the ordinary one, — alcoholic lypemania with delusions of persecution. 
It is asserted that there is also an alcoholic megalomania, in which there 
are expansive delusions or hallucinations of sight and hearing, which in 
most instances relate to God and a future state. In an ecstatic exaltation 
the patient is enrapt by visions of supernatural beings, or basks in the 
presence of the Deity ; ministering bands of angels speak words of com- 
fort to him, or, it may be, the voice of God himself is heard in command 
or instruction. 

Prognosis. — Alcoholic insanity usually gets well if the symptoms are 
those of the ordinary type as given above, provided there be no renal 
disease or other serious complication. It should, however, be remem- 
bered that the habitual use of alcohol may aid in the development of 
an ordinary insanity, which, having other etiological roots, cannot be 
properly called alcoholic insanity, and may readily be incurable. A 
true alcoholic insanity which has lasted for a length of time under the 
habitual excessive use of alcohol, or which has followed numerous attacks 
of delirium tremens, may be permanent. 

Treatment. — The treatment of alcoholic insanity consists primarily 
in the absolute withdrawal of the alcohol. There may be cases in which 
it is not safe to take away the narcotic at once, but we cannot remember 
to have ever seen one. Eestraint should always be enforced, by isola- 
tion in an institution unless the patient's pecuniary circumstances are 
such that private isolation and abundance of nurses are possible. Such 
restraint is necessary for the purpose of enforcing the abstinence from 
liquor, but it is still more essential because the person suffering from 
alcoholic insanity is always a dangerous lunatic. 

Hyoscine hydrobromate, the bromides, opium, or chloral, must be used 
judiciously to secure quiet and sleep. Blisters to the back of the neck 
are sometimes valuable. Hot baths and hot packs are often of service 
in allaying the general irritation. Aconite, digitalis, and other arterial 
sedatives or stimulants are to be used in accordance with the needs of 
the individual case. It is necessary to pay very careful attention to the 
digestive organs, as chronic gastritis and hepatic congestion are ordinary 
complications. As much simple nutritious food should be given as can be 
digested, the tendency of the disorder being distinctly asthenic. Quinine 
rarely does good, and is apt to irritate the stomach. Strychnine is often 
of great service, especially in the more chronic cases. 

OPIUMISM. 

The excessive habitual use of opium produces general failure of health, 
usually with derangement of digestion, and nervous symptoms which re- 
semble those of neurasthenia to some extent. There are no characteristic 
phenomena, but when in any case of apparently causeless failure of health 
the patient at times is dreamy, with an indolent, quiet, dolce far niente 



POISONING. 



375 



manner, the practitioner's suspicions should be aroused. Not rarely 
great suspiciousness exists, and delusions of persecution often occur. 
Very frequently the delusions take a sexual tinge, and the belief in un- 
faithfulness on the part of a marital partner is not uncommon. On the 
other hand, in many cases there are no delusionary tendencies, even in 
the last stages of opium poisoning. The peculiarity of the beliefs is their 
unfixedness, so that the subject may seem one day entirely free from any 
disorder of mental action, and the next day may have a distinct delusion. 

Infants, born of a mother who is a heavy opium-eater, often appear 
healthy at the time of birth, but suddenly, without apparent cause, 
within two or three days pass into a condition of collapse, ending in 
death. There can be little doubt that in such cases the cause of the 
collapse is the sudden withdrawal of the opium to which the child had 
become accustomed whilst in the uterus, and it would seem, therefore, a 
rational procedure cautiously to give opium to such a child for a time 
after its birth. 

Treatment. — No confidence can be placed in the statements of the 
opium-eater, and it is essential for cure that such person be in a hospital 
or be confined to an apartment under the care of an absolutely reliable 
nurse, so that the orders of the physician can be strictly enforced. The 
basis of the treatment must consist in the withdrawal of the narcotic, and 
there are three ways in which this can be effected. First, the opium 
may be suddenly taken away j secondly, it may be taken away rapidly, 
but not suddenly ; thirdly, it may be withdrawn very gradually. The 
first of these methods is undoubtedly in most cases efficient, but is often 
attended with grave danger of collapse, and has no distinct advantages 
over the plan of rapid withdrawal. The time required for the very 
gradual withdrawal of the remedy is too great for practical purposes, and 
the sufferings of the patient are too long drawn out. Unless the daily 
dose has been extraordinary or the patient is in a very feeble condition, 
it is safe to withdraw the narcotic completely in from seven to twelve days. 
An excellent plan is to direct that a solution of morphine or opium be 
prepared, and that whenever a dose is taken out an equivalent amount 
of water be added. In a successful case of a woman who took three 
pints of paregoric daily, we had prepared a gallon of paregoric and 
also a supply of paregoric without opium in it. Whenever a dose of 
the true paregoric was taken out the demijohn was filled up with the 
pseudo-paregoric. The chief symptoms that follow the rapid withdrawal 
are excessive malaise, insomnia, complete loss of appetite, vomiting, 
diarrhoea, and great feebleness. Very rarely these symptoms become so 
uncontrollable as to warrant alarm for the safety of the patient. Much 
may be done by proper feeding. The food should consist of highly nu- 
tritious, stimulating, and easily digested articles, and in severe cases 
should be liquid, such as milk, rich soups, etc. When the circulation 
fails, alcohol may be used, and much relief may be afforded by massage, 



376 



GENERAL DISEASES. 



and often by simple rubbing of the patient. General electrical stimulation 
and faradization of the muscles are often useful, not only by their effect 
upon the circulation, but also by distracting the attention of the patient 
from his sufferings. The use of the alkaloid cocaine as a stimulant has 
been recommended. We have seen apparently very good results from the 
free internal administration of the fluid extract of coca, but the use of 
hypodermic injections of cocaine is scarcely justifiable, on account of the 
danger of setting up the cocaine habit. If gastro-intestinal irritation 
exists, bismuth may be administered freely. The diarrhoea is usually 
controllable by mild astringents, especially if combined with sulphuric 
acid. If the bodily temperature falls, it must be maintained by external 
warmth. Potassium bromide, ammonium valerianate, Hoffmann's ano- 
dyne, and other similar feeble nerve-sedatives may be employed and give 
some comfort. Moral support and stimulation are essential, and any de- 
vice which aids in passing the time of suffering is beneficial. 

COCAINISM. 

In America the third in importance of the narcotic habits is that 
which is known as " cocainism." In the symptoms there is nothing 
which is characteristic. Failure of health, indigestion, disturbances 
of circulation, with rapid pulse and sometimes shortness of breath, a 
pasty yellowish or even bronze skin, and various nervous disturbances, 
may be the results of the excessive use of the alkaloid. According to 
Mattison, hallucinations and delusions, with homicidal mania, are fre- 
quent, and a peculiar pathognomonic symptom is the impression that 
there is some foreign body under the skin, especially about the finger- 
tips, which leads the subject to dig continually at himself with some 
instrument. 

In every case of abuse of cocaine which we have seen the subject has 
been addicted to other narcotic habits, and we believe that pure cocainism 
is very rare in the United States. According to our observations, it is 
entirely safe to withdraw the drug at once ; at least we have so done 
in persons who were taking as high as fifteen grains of cocaine hydro - 
chlorate a day, without the production of any severe symptoms. The 
general treatment should be very much like that for the morphine habit. 
The symptoms must be met as they arise, and the patient supported by 
all possible means. 



SECTION II. 

DISEASES OF THE NERVOUS SYSTEM. 



CHAPTEE I. 

GENERAL SYMPTOMATOLOGY. 

Those disturbances of the functions of the nerve-centres or of the 
peripheral nerves which constitute the symptoms of disease are best out- 
lined under the headings of Disturbances of Motion, voluntary, invol- 
untary, and reflex ; of Coordination ; of Sensation ; of Vaso-motor and 
Trophic Functions ; and of Intellection, including personal character 
and emotions. 

DISTURBANCES OF MOTION. 

Paralysis, or true loss of motor power, must be distinguished from 
the loss of motion due to local disease not connected with the nervous 
system. This pseudo-paralysis can usually be recognized by the fact 
that passive motion or local pressure gives pain. When, however, con- 
tractures exist, or when peripheral nerves are diseased, there may be a 
true paralysis although there is soreness to pressure and passive move- 
ments are painful. 

An entire loss of power is known as a complete paralysis ; a partial 
loss, as an incomplete paralysis, or a paresis. A general paralysis is a loss 
of power in the whole body below the head : it is never absolutely com- 
plete, since death from loss of power in the respiratory muscles must 
result before such condition is reached. The loss of power may, however, 
be complete in the arms and legs. Hemiplegia is paralysis of one lateral 
half of the body ; but, as it is very rare for the respiratory muscles to be 
paralyzed, this term is universally used not only when the face, arm, and 
leg are paralyzed, but also when only the arm and leg are affected. 
Hemiplegia is almost invariably of brain origin. A cross paralysis is 
one in which one side of the face and the opposite side of the body are 
affected. Paraplegia is paralysis of the lower transverse half of the 
body, and is almost always due to disease of the spinal cord. Mono- 
plegia — that is, paralysis of one part — may be facial, brachial, or crural. 
A local paralysis is a palsy of a single muscle or muscle-group. A multiple 
paralysis is an association of local paralyses, — i.e., a paralysis of groups 

377 



378 



DISEASES OF THE NERVOUS SYSTEM. 



of muscles more or less scattered and having no direct connection. Mono- 
plegia, local paralysis, and multiple paralysis may be due to lesions of 
the brain, the spinal cord, or the nerve-trunk. The brain lesion in such 
a case is almost invariably in the cortex, while the spinal lesion is in the 
ganglionic cells of the anterior cornua. The loss of movement which 
constitutes a paralysis can usually be seen at once ; in paralysis of the 
face the mouth is drawn away from the affected side unless contractures 
have taken place in the paralyzed muscles, and in lingual paralysis the 
protruded tongue is thrust towards the paralyzed side. In paresis of 
the forearm it is customary to note the exact power of grasp by means of 
the dynamometer. Various apparatuses have been devised for testing 
loss of power in the leg, but in practice a sufficiently accurate judgment 
can be made by noting the extent of forced movements, the amount of 
endurance in walking or in standing on one leg, the ability to rise out 
of a chair, etc. 

Convulsions. — Three types of convulsions are recognized : the epi- 
leptiform, or cerebral, in which consciousness is completely lost ; the 
hysterical, in which consciousness is disturbed ; and the tetanic, or spinal, 
in which consciousness is normal and reflex activity is grossly exagger- 
ated. These varieties of convulsions grade one into the other. A detailed 
discussion of convulsions will be found in various articles, especially in 
those on Epilepsy and Hysteria. 

Automatic Movements. — Automatism is the condition which some- 
times occurs in epilepsy, the hypnotic state, etc., in which the subject 
performs seemingly voluntary purposive acts without clear consciousness 
or after- memory. A purposive act,* involving a more or less elaborate 
series of movements, performed as the result of an entirely irresistible 
impulse, is spoken of as automatic, although there may be complete 
consciousness during the whole time. Automatic acts must be clearly 
separated from choreic movements. 

Reflexes. — For the performance of a reflex action there must be a 
complete arc composed of afferent nerve with its root, motor ganglion- 
cell, efferent nerve with its root, and muscle. Any disturbance of this 
arc may register itself in disturbance of reflex activity. A deep reflex is 
one elicited by irritation of a deep structure ; a superficial reflex is brought 
about by a superficial irritation. 

Of the deep reflexes the most important are the patella reflex and the 
aiikle reflex. The patella reflex (WestphaVs symptom, Tcnee-jerTc) is the 
movement which is elicited by striking the patellar tendon. In testing 
for it, it is better to have the leg hanging loosely over a chair or a cane, 
and to strike a sharp quick blow with the tips of the bent fingers or 
with a small rubber hammer prepared for the purpose ; or the blow 



* A purposive act, as the term is used in this work, is an act which is appar- 
ently but not really performed for a purpose. 



GENERAL SYMPTOMATOLOGY. 



379 



may be delivered with the foot placed upon the ground and the contrac- 
tion of the rectus femoris be felt with the hand. Marie asserts that in 
many cases there is a simultaneous contraction of the adductors of the 
opposite thigh, and that in disease this may persist when the knee-jerk 
is lost. Any voluntary movement, such as clenching the hands, strain- 
ing, or even winking, made at the time of the delivery of the blow, in- 
creases (technically, reinforces) the contraction. The knee-jerk is prob- 
ably absent in about two per cent, of normal individuals ; according to 
our experience it is quite frequently absent in the Latin race living in the 
tropics. It may also be absent as the result of disease not connected with 
the nervous system ; any affection, such as emphysema, which produces 
defective aeration or oxidation of the blood, has a tendency to destroy it. 
In Dr. Eussell's experiments upon the dog, asphyxia produced a primary 
increase followed by a loss of the knee-jerk. It may also disappear as the 
result of various diseases which lower the muscular tone, such as dia- 
betes, also after diphtheria, even at a time when there is no indication of 
peripheral neuritis. It is, however, often exaggerated when the muscu- 
lar system and the general vitality are much enfeebled, as in phthisis, 
and, it is asserted, even in acute disease such as typhoid fever. It may 
be increased or decreased by disease in or about the cerebellum, but 
lesions of the nervous system affecting it are usually situated either in 
the spinal cord or in the nerve-trunks. 

Clonus is a to-and-fro movement produced by sudden stretching of a 
tendon, with or without a blow upon the stretched tendon. It is never 
present in normal individuals ; it is very rarely producible under any 
circumstances in the elbow, wrist, and jaw, but may often be elicited in 
the ankle during spinal disease or hysteria. Ankle- clonus is best ob- 
tained by suddenly and forcibly flexing the foot with one hand placed 
upon the ball whilst the leg is held by the other hand. In doubtful cases 
a sharp quick blow may be struck upon the stretched tendon. In some 
persons a biceps or elbow jerk may be elicited by allowing the half- flexed 
arm to rest supinely in one hand and tapping the biceps or flexor tendon 
of the arm with the fingers or the hammer. A still rarer reflex is the 
jaw or chin reflex, which may sometimes be obtained by allowing the 
jaw to hang passively or gently supported in one hand, whilst a quick 
blow is struck upon the chin from above downward. 

Paradoxical contractions are produced by suddenly relaxing the 
muscle, as happens to the anterior muscles of the leg when the foot is 
forcibly flexed by another person : they are probably never present in 
normal individuals, and are usually neurasthenic or hysterical in origin. 

A spasm is an involuntary non-permanent contraction of the muscles, 
which must be separated from the contracture, which is a permanent 
shortening or contraction of the muscles. A spasm may be clonic or 
tonic. A contracture may be due to the disease of the muscles affected 
or of the nerve apparatus to which the muscle is tributary ; or it may 



380 



DISEASES OF THE NERVOUS SYSTEM. 



be the outcome of a long- continued lack of power in an antagonistic 
muscle. 

A tremor is a to-and-fro vibratile movement, caused by more or less 
rhythmical contractions of antagonistic muscles. Tremors are of two 
kinds, — those which occur whether the subject be at rest or in motion 
{persistent tremors), and those which cease when there is absolute rest 
(intention tremors). A persistent tremor may, however, cease during 
sleep. Persistent tremors may be due to old age, to various poisons, such 
as alcohol, tobacco, mercury, etc., to general paralysis, or to paralysis 
agitans. The intention tremor is usually the outcome of a multiple 
cerebro-spinal sclerosis, although some toxic tremors, especially those 
of mercury, may simulate an intention tremor. 

Choreic movements are irregular movements due to independent con- 
tractions of single or associated groups of muscles 5 they may closely 
simulate purposive movements, and probably in some cases are exag- 
gerations of such movements, but they never form a complicated series 
of apparently purposive actions. They vary in intensity from a slight 
restlessness or a slight movement of the fingers or toes to the most 
severe constantly recurring motions. They may be confined to one or 
more groups of muscles (local chorea), or they may affect the entire mus- 
cular system (general chorea). Usually they are not regular, rhythmical, 
or consentaneous 5 in certain cases, however, movements more or less 
resembling tremors, but slower and more extensive, occur, and are known 
as rhythmical chorea. Choreic movements may be produced by lesions 
affecting any of the ganglionic cells in the cerebral or pyramidal tract, 
and are, therefore, no more uniform in their significance than is paralysis. 
Generalized choreic movements (chorea of many authors) may be caused 
by St. Vitus' s dance, Huntingdon's disease, local irritation, organic dis- 
ease of the nerve-centres, pregnancy, old age, and hysteria. 

Hemichorea is a disordered, irregular, persistent movement of one 
side of the body, not ceasing during rest, exaggerated by voluntary move- 
ments or by concentration of the attention. It is distinguished from 
tremors by its irregularity and by the extent of the movements. A form 
of hemichorea is the so-called athetosis (adezdq, without fixed position), 
which is characterized by an incessant movement of the fingers and toes, 
and by the impossibility of maintaining these parts in any position in 
which they have been placed. 

DISTURBANCES OF COORDINATION. 

Coordination may be disturbed in the whole organization or in the 
arms or the legs separately. The first test of coordination is the so-called 
station test, in which the individual is placed strictly erect, with the heels 
and toes of the two feet closely approximated, when, if coordination 
be imperfect, the swaying of the body will be beyond the norm, and 
movement may become necessary. The test will be more delicate if the 



GENERAL SYMPTOMATOLOGY. 



381 



patient be required to stand on one foot. The patient should be fur- 
ther required to walk a chalk-line, to walk backward, to turn suddenly, 
then with the eyes shut to stand and to walk backward and forward. 
Care is sometimes necessary to avoid mistaking the awkwardness that 
arises from muscular weakness or stiffness, or from the vertigo of cerebral 
disease, for true loss of coordination. The peculiar form of disorder of 
coordination known as titubation is described under Cerebellar Disease. 

Disturbance of coordination in the arms produces the loss of power 
of executing delicate movements. The usual test is for the patient to 
close the eyes, clench the hands with extension of the index fingers, and 
then, opening the arms widely, rapidly bring the index fingers together, 
first with the eyes open, then with the eyes shut. If coordination be 
imperfect, the points of the fingers will not come in contact. 

DISTURBANCES OF SENSATION. 

In the study of sensation, algesia, or the power of feeling pain, must 
be distinguished from sensibility, which itself is naturally divided into the 
sense of touch, or the power of recognizing contacts ; electrical sensibility, 
or the power of recognizing electrical currents ; thermic sensibility, or 
the power of recognizing the temperature of bodies ; pressure-sense, or 
the power of recognizing weights ; and muscular sense, or the power of 
estimating muscular movements. An aesthesiometer is used for the testing 
of the sense of touch ; it may consist of ordinary compasses with blunted 
points, furnished with a graduated scale, or of a pair of blunt points one 
of which slides upon a graduated bar. When applied evenly and simul- 
taneously to the surface the two points may be felt as two or as a single 
point, according as they are more or less widely separated. The sensi- 
bility varies not only in different parts of the skin, but also in the same 
portions of the skin in different individuals ; usually, therefore, it is 
better to compare the affected part with the opposite side of the body : 
any wide deviation, however, from the following scale may be regarded 
as abnormal : the upper surface of the tongue, 1.18 mm.; the tips of the 
fingers, 2.25 mm.; the side of the first phalanx, 16 mm.; the back of 
the hand, 3.1 mm.; the upper arm and the thigh, 3.7 mm. 

Thermo-a3Sthesiometers are used for testing the thermic sensibility, 
but a series of test-tubes filled with water of different temperatures will 
afford all the necessary apparatus for the purpose. The most accurate 
temperature range lies between 81° and 86° F., then between 91° and 102° 
F., and, lastly, between 57° and 80° F.; above or below these limits the 
sense is lost in the sensation of pain. According to Nothnagel, the 
smallest perceptible differences of temperature are the following : on the 
breast, 0.72° F. ; on the back, 1.62° F. ; on the back of the hand, 0.54° F. j 
on the palm of the hand, 0.72° F.; on the arm, 0.36° F.; on the back of 
the foot, 0.72° F.; on the lower extremities, 0.90° to 1.08° F.; on the 
cheek, 0.36° to 0.72° F.; on the temples, 0.54° to 0.72° F. Few normal 



382 



DISEASES OF THE NERVOUS SYSTEM. 



individuals, however, recognize temperature so accurately. Pressure- 
sense is tested by placing graduated weights upon the hand, foot, etc. , 
whilst lying upon a firm hard surface. Various apparatuses have been 
devised, but it is possible to make a regular series of weights which will 
suffice by partially filling shot-gun cartridges with shot. The muscular 
sense may be tested by noting the power of the patient to recognize the 
amount of various weights when lifted ; it is usually better to test one 
hand against the other than to rely upon the accuracy of the patient's 
statements as to the amount of the weight lifted. 

Loss of sensibility is spoken of as anwsthesia ; excessive sensibility, as 
hyperesthesia. Hyperesthesia, as the term is commonly used, must be 
distinguished from simple tenderness ; it is a condition of excited func- 
tional activity of the nerves of the skin or other parts with which contact 
can be made, not dependent upon any local disease. Paresthesia is the 
term applied to all forms of abnormal sensation which are not actual 
pain, such as formication, or the feeling of the crawling of insects, the 
sensation of running water upon the skin, etc. 

VASO-MOTOR AND TROPHIC DISTURBANCES. 

Vaso-motor disturbances produce alteration in the color of the affected 
part, and usually in the temperature. Trophic alterations cause changes 
of form and structure which are readily recognized by the eye, so that 
no further discussion of them here seems necessary. 

DISTURBANCES OF INTELLECTION. 

In the outline sketch of mental diseases such as is alone possible 
in the present volume, the human intellectual faculties may be sepa- 
rated into the Will, the Intellectual Faculties proper, — such as Memory, 
Eeason, Imagination, — the Emotions, — such as Fear, Anger, — and finally 
Character. For our present purposes the alterations of these functions 
produced by disease may be studied under the headings of Excitation, 
or increased functional activity ; Depression, or lowered functional ac- 
tivity ; and Perversion, or perverted functional activity. 

Will. — The will is the inhibitory function of the brain. It arrests or 
dismisses thought and intellectual activity in general ; it checks or keeps 
down emotions. Man can control a passion by the will, but he cannot 
directly will himself into a passion. He can stimulate, if he desire, an 
emotion by bringing before the mind thoughts which act as a stimulant 
to this emotion. Abnormal excitation (hyperbulia) of the will — i.e., of 
the inhibitory brain function — is a somewhat rare phenomenon, difficult 
of recognition. The excessive obstinacy and self-assertion often seen in 
mental disorder are usually rather the outcome of a weakened will than 
of an overpowering egoism, the person being obstinate or aggressive 
because his will is enslaved by a lower intellectual or emotional nerve- 
centre. Thus, in melancholia inflexible obstinacy may result from the 



GENERAL SYMPTOMATOLOGY. 



383 



despotism of a depressive emotion, or a dominant idea may absolutely 
rule the individual. In hysteria the will is probably always feeble, but 
the persistence and apparent wilfulness of hysterical subjects are pro- 
verbial. Again, in chronic alcoholism the extraordinary persistency of 
the subject in the pursuit of alcohol is the outcome of a weakened will 
which is dominated by an appetite. 

Abnormal weakness of the will (abulia) may be the result of acute 
illness, starvation, intoxication, age, chronic disease, or any other influ- 
ence which lowers the nutrition of the brain-cortex. Concerning perver- 
sion of the will we have no knowledge. 

Intellectual Faculties. — Absolute increase of mental power is very 
rare, and is never present in any advanced stage of disease. Its subject 
has a passion for intellectual labor, with an abnormal power of accom- 
plishing : without fatigue and without pain the attention is kept concen- 
trated for hours, both the quality and the quantity of the work being 
beyond that which is normal to the individual. Mental exhilaration is 
probably always associated with acute hyperemia, and usually with pro- 
nounced insomnia. It may come on as the result of protracted mental 
labor, especially when stimulants have been employed, and may be the 
prodrome of severe mental disease, such as acute encephalitis or paretic 
dementia. It is always a very dangerous condition, and should be the 
signal for immediate cessation of mental effort and for careful medical 
treatment. 

Failure of the mental powers (amentia when complete, dementia when 
partial) is a very common result of brain- disease. In its earliest begin- 
nings mental failure usually reveals itself in loss of memory and of the 
power of fixing the attention. Fixation of the attention depends upon 
the exertion of the inhibitive power of the will in repressing distracting 
thoughts and shutting out new perceptions. Persistence in it is a large 
feature in all severe intellectual work, and when the brain is becoming 
exhausted, mental toil grows more and more irksome, not simply nor 
even chiefly because the reasoning faculties labor with difficulty, but 
because the will is unable to shut out the influences of distracting 
thoughts, emotions, or perceptions. Failure of memory and failure of 
the power of attention may coexist, and, if of severe type, in their co- 
existence usually indicate organic brain- disease. Failure of memory, 
when very pronounced, even if it exist by itself, usually depends upon 
incipient brain- disease, but the loss of the power of fixing the atten- 
tion, when it exists alone or is accompanied by only a slight failure of 
memory, is commonly due to cerebral asthenia. 

Incoherence may be due to mental excitement or mental depression, 
constituting the so-called acute and passive incoherence. In acute in- 
coherence a heightened or irregular cerebral activity manifests itself 
in an excessive rapidity of intellectual acts lacking connected sequence. 
Before one idea is fully conceived, much less expressed in words, another 



384 



DISEASES OF THE NERVOUS SYSTEM. 



rushes into existence and demands utterance, so that a confusion of talk 
results. Passive incoherence is, on the other hand, due to a lack of 
mental power which prevents the completion of the mental act, or, at 
least, its expression in words. In the acute incoherence of the raving 
maniac the rapid utterances are but the hints of the infinite crowd of 
jostling ideas ; whilst the slow, confused, disconnected, hesitating words 
of the demented are evidently the outcome of a failure to conceive. It 
must, however, he remembered that in many cases mental excitement 
coexists with failing power, so that a mixed type of incoherence is pro- 
duced. 

Under the heading of Perversions of the Intellectual Powers we shall 
discuss certain phenomena seen in mental disease which can hardly be 
said to be due to exaltation or depression of the mental functions, al- 
though they are often associated with a true loss of mental power. 

A sensation which is produced by an external object is spoken of as 
objective. A sensation which is the result of some change in the sense 
organs and is independent of external objects is subjective. An external 
object may give rise to such a distorted, misleading perception that the 
subject really says or feels or hears that which has no existence, as in 
mirage. Such a distorted perception is known as a false perception, or 
sometimes as an illusion. If, however, a perception be entirely sub- 
jective, — i.e., if it be the conscious recognition of a sensation which is 
not due to any impulse received by the perceptive apparatus from with- 
out, but arises within the perceptive apparatus itself, — it is an hallucina- 
tion. In nature illusions and hallucinations grade into one another, there 
being no sharp line, on the one hand, between pronounced illusions and 
slight distortions of objective sensations, nor yet, on the other hand, 
between hallucinations and illusions which have been provoked by the 
slightest and most indefinite of external stimuli. An hallucination has 
no definite diagnostic import. It may be due to the direct or indirect 
action of a poison, to cerebral exhaustion, or to peculiar conditions of 
the nerve-centres produced by various agencies. An hallucination does 
not necessarily depend upon or have connection with intellectual un- 
soundness. It is, however, often associated with such unsoundness, 
because the condition of the sensory brain-tract which produces it is apt 
to accompany a similar condition of the higher or intellectual centres. 
It often affords a test of the condition of the upper brain-centres. If the 
judgment fails to correct the testimony of the disordered sense by impres- 
sions derived from other senses, the subject is of unsound mind. If an 
individual, for example, cannot be made to believe that the vision which 
he sees or the false voice which he hears has no existence, then is his 
judgment dethroned. It is not the seeing of the vision, but the loss of 
the power of weighing evidence, which is at once the outcome and the 
proof of the intellectual degradation. Under the circumstances just 
spoken of, the hallucination gives rise to a delusion, a term which as used 



GENERAL SYMPTOMATOLOGY. 



385 



by the alienist is a synonyine for insane delusion. A delusion may be de- 
fined to be a faulty belief concerning a subject capable of demonstration 
out of which the person cannot be reasoned by methods which should be 
adequate. An insane hallucination is a false fixed perception 5 an insane 
delusion is a false fixed belief. The existence of a delusion is commonly 
considered proof of insanity j but, whether it be an hallucination or a 
delusion that is in question, the real proof of mental unsoundness is the 
failure of the judgment to correct the disordered perception or belief. 
In either case the essence of the insane mental state is the loss of power 
to receive and weigh adequate evidence. The nature of delusions varies 
so indefinitely as almost to defy classification, but the most important 
forms of delusions are, first, expansive delusions 5 second, hypochon- 
driacal delusions 5 third, delusions of persecution. 

An expansive delusion is an exaggeration of greatness or goodness or 
power ; it usually concerns the personality of the individual. Thus, a 
man having a delusion of grandeur believes that his prowess is irresist- 
ible, his wealth incalculable, or his future prospects unbounded. Hypo- 
chondriacal delusions relate to disease of the person, and of all delusions 
are those in which the gradations between the sane and the insane 
belief are most subtile. Almost every chronic invalid exaggerates his 
symptoms, and even the man who clearly has hypochondriacal delusions 
often has some physical basis for his beliefs. Delusions of persecution are 
those in which the patient believes that he is the object of the active 
antipathy of his fellows. They always constitute an element of danger, 
their subject being impelled by motives of revenge or of fear to kill the 
persecutors. They are especially dangerous when the delusion attaches 
itself to one or several individuals and is not generalized. 

When the subject of a delusion reasons about and defends more or less 
logically his delusion, such delusion is said to be systematized. Thus, if a 
person who has a delusion that his soul is lost simply reasserts his belief 
under opposition, and assigns no reason for it, his delusion is unsystem- 
atized ; but if he affirms that he has committed the unpardonable sin, and 
quotes Scripture to show that his doom is, under the circumstances, the 
proper one, then is his delusion systematized. Great diagnostic value 
is attached by some writers to the distinction between systematized and 
unsystematized delusions. There is, however, in fact, every gradation 
between the most thoroughly systematized delusion and that which is 
most completely isolated ; so that in this as in all other respects the two 
great groups of insanities hereafter to be spoken of pass insensibly into 
each other. 

An imperative conception is a general idea which, usually without ob- 
vious cause, arises in the brain of a person and dominates his action, 
although its falsity is recognized by the individual. The imperative con- 
ception may give rise to the morbid impulse,— that is, a dominating desire 
to do a certain act. Frequently, however, the morbid impulse exists 

25 



386 



DISEASES OF THE NERVOUS SYSTEM. 



without its being possible to discover any imperative conception. The act 
which results from the morbid impulse is spoken of as an imperative act. 
It is clear that the imperative conception is not necessarily a delusion, 
but when the patient fails to recognize the untruthfulness of the impera- 
tive conception the conception becomes a delusion. To illustrate what is 
meant by an imperative conception, morbid fears, as among the most fre- 
quent forms of this disordered mentality, may be selected. These morbid 
fears may be an exaggeration of a normal feeling. Thus, an exaggeration 
of the natural dislike for filth gives rise to mysophobia, or the fear of 
contamination, but the overwhelming horror of walking under an open 
sky (a common form of these fears) seems to be based upon no natural 
feeling. 

If the sufferer from a morbid fear clearly perceives that his fear is 
not natural and has no basis in fact, there is no delusion, although the 
morbid fear may dominate the acts of the individual. Thus, a myso- 
phobic will refuse to open a door, to pick up any object, to handle any 
money except it be new, to shake hands, etc., all simply through a 
groundless fear of contamination (the true nature of which he recognizes), 
or a person having the fear of leaving things crooked will spend hours in 
picking up and laying down an object ; here a distinct morbid impulse 
grows out of a morbid fear.* 

By the use of the word mania as a suffix, numerous names have been 
formed which are sometimes incorrectly used as denoting the morbid im- 
pulse. It must also be clearly borne in mind that these so-called manias 
are not distinct diseases. In pyromania the morbid impulse is to start 
conflagration ; in kleptomania, to steal ; in arithromania, to be perpetually 
making calculations. By a similar fallacious nomenclature, morbid de- 
sires or exaggeration or perversions of natural appetites give rise to a 
number of so-called manias. Thus, the condition of uncontrollable sex- 
ual excitement is known in the female as nymphomania, in the male as 
satyriasis. Erotomania is a condition in which there is the appearance 
but not the reality of sexual excitement ; the subject of it conceives (or 
believes that he has conceived) a strong attachment for some person of 
the opposite sex whom, probably, he has never seen, and lives in an atti- 
tude of perpetual worship of his inamorata. Whilst satyriasis leads to 

* To many of these m'orbid fears names have been given by systematic writers. 
The fears, however, vary so greatly that it seems impossible to have any accurate 
system of classification or nomenclature. The following list, taken from Dr. Beard, 
portrays very well the absurdity of the attempt, and at the same time suggests some 
of the common forms of morbid fears : 

Astraphobia, fear of lightning ; Topophobia, fear of places (a generic term, with 
these subdivisions : Agoraphobia, fear of open places ; Claustrophobia, fear of narrow, 
closed places) ; Anthrophobia, fear of man, — a generic term, including fear of society ; 
Gynephobia, fear of woman ; Monophobia, fear of being alone ; Pathophobia, fear 
of disease,— usually called hypochondriasis ; Pantaphobia, fear of everything ; Phobo- 
phobia, fear of being afraid ; Mysophobia, fear of contamination. 



GENERAL SYMPTOMATOLOGY. 



387 



sexual excess and to rape, erotomania is a platonic affection, which in- 
volves rather the higher conceptive sphere than the lower nerve-centres, 
and leads to sexual abstinence. 

Both imperative conceptions and morbid impulses are undoubtedly 
frequent in the insane, but they may exist in persons whose intellectual 
actions in other respects are within the limit of sanity, and in whom the 
judgment is not dominated by the conception, although the conception 
and its consequent morbid impulse may cause the person to perform 
actions which are against his judgment. To himself such a subject 
seems possessed by a demon whom he must obey. A very intelligent 
patient once aptly compared the controlling force of the impulse to the 
besoin de respirer : for a time it could be restrained, but finally it must be 
obeyed. Such persons may be successful business men and useful citi- 
zens, and it is evident that they should not be considered legally insane 
or be put under restraint unless the morbid impulse is of such character 
that it endangers the safety of others. 

The relations of morbid conceptions and impulses to legal responsi- 
bility may involve questions of great practical difficulty. The victim of 
a morbid impulse cannot properly urge such impulse as a legal excuse 
for crime unless such crime has been committed in immediate obedience 
to the impulse. Thus, a person who had the morbid impulse to kill 
could not plead the existence of such an impulse as a defence for theft. 
Further, when the act has been committed because the actor has been 
forced to do it by a morbid impulse which he could not possibly control, 
the actor remains morally blameless ; but who can tell in any concrete 
case whether the impulse was resisted to the uttermost ? Moreover, the 
needs of society and the ease with which such impulses may be alleged 
or counterfeited very properly give us pause in attempting by them to 
excuse a criminal act j whilst the claims of humanity may draw towards 
mercy for the alleged criminal, the interests of general human life, the 
good of the great mass, may well urge the execution of the laws. Cer- 
tainly, under all circumstances the clearest possible proof should be 
required that the impulse had existed and had been recognized by others 
than the sufferer himself on occasions previous to the commission of the 
crime ; and, further, it should be made probable that the impulse was 
really morbid and irresistible at the time of the crime. 

An intellectual attribute which underlies all intellectual work and 
carefully considered action is confidence in one's own mental processes. 
When this confidence is naturally slight, the individual is timid and 
indecisive ; when it is excessive, he is bold and prompt in action. In 
certain diseased conditions this confidence may be entirely lost, giving 
rise to the so-called delirium of doubt. This may occur without any other 
demonstrable disturbance of the mental faculties, and reveal itself in 
action, the patient continually repeating the act because he or she is 
uncertain that it has been completed. Thus, in the case of a mother 



388 



DISEASES OF THE NERVOUS SYSTEM. 



under our observation, a large portion of the night would be passed in 
changing the diaper of an unfortunate babe, because the woman was 
never certain that her memory of having changed the diaper was correct 
or that her present perception of the dryness of the diaper was accurate. 

Emotion. — Human emotion may be depressed or exalted by disease ; 
but we find that, owing to inaccurate thinking, there is in literature a 
complete departure from the proper use of the words u exaltation" and 
" depression" in regard to emotional condition. In advanced cerebral 
disease there may be a condition of true emotional enfeeblement, so that 
circumstances which would have affected most vividly the individual 
in his normal condition fail to elicit response. This mental condition 
should logically be known as emotional depression, but it is the apathy 
of writers. It is to be clearly distinguished from that condition which is 
produced by the excitement of the depressive emotions, such as grief, — 
a condition which, however, is the emotional depression of authors. A 
person suffering from melancholia is not in a condition of emotional de- 
pression in the correct sense of the term, but in one of emotional excite- 
ment, — i.e., excitement of a depressive emotion. It is true that excite- 
ment of a depressive emotion is frequently associated with a general 
depression of the nervous system ; but this is not always the case, and 
the victim of melancholia agitata is in a state of general nervous erethism 
or excitement. The use of the terms is, however, so fixed in language 
that it is impossible to escape from them without running the risk of 
confusion, and therefore we shall in the present volume use the terms 
" emotional depression" and " emotional excitement" in their ordinary 
meaning, — i.e., as respectively representing excitement of the depressive 
emotions and excitement of the emotions of exaltation. 

It is often necessary to distinguish between a true apathy or lack of 
emotional power and the pseudo-apathy in which the patient is rendered 
oblivious to external influences because he is overwhelmed by a fixed 
idea or by an internal emotional excitement. Thus, a man who believes 
that he is to be devoured by the flames of hell may be dumb through fear 
and despair, or, as the German alienists say, " thunderstruck." 

Human character is the result of the balance between the will, the 
intellectual attributes, and the emotional forces of the individual, so that 
any disturbance of one of these correlated factors must produce a corre- 
sponding change in the character of the individual. Character is, there- 
fore, always seriously implicated in mental affections, and intellectual or 
emotional disturbances so subtile as not to be readily perceived some- 
times register themselves plainly on the dial -plate of character. Hence 
alterations of character are always significant, and are not infrequently 
the first evidences of serious disease. In studying any case of alleged but 
doubtful insanity, it is therefore of the greatest importance to contrast, 
if possible, the individual as he now is with himself as he was when in 
full, undisputed health. 



FUNCTIONAL NERVOUS DISEASES. 



389 



CHAPTEE II. 

FUNCTIONAL NERVOUS DISEASES. 

Nervous diseases may be divided into the organic and the functional, 
although, strictly speaking, there is no such thing as a functional disease, 
all diseases being, without doubt, attended with alteration of structure ; 
but as there are numerous nervous diseases whose pathological basis is 
too delicate to be detected by our methods of examination, and as there 
are other nervous diseases not yet sufficiently studied for a conclusion to 
be reached, it is convenient to group together in a chapter like the present 
all nervous diseases whose pathology is not established. Again, in the 
present imperfect state of our knowledge it seems necessary to have arti- 
cles upon certain symptoms, such as headache, vertigo, etc., because in 
daily practice these symptoms seem to patients to be distinct diseases, 
and require special knowledge and skill on the part of the practitioner. 
In the present chapter are therefore included Symptomatic Conditions, 
and Diseases of Unknown Pathology. 

INSANITY. 

Definition. — Insanity is a condition of mental aberration sufficiently 
intense to overthrow the normal relations of the individual to his own 
thoughts and actions, so that he is no longer able to control them through 
the will ; this condition being independent of known structural altera- 
tion of the brain.* 

GENERAL CONSIDERATIONS. 

The definition of insanity which has just been given is necessary rather 
for medico-legal purposes than for the immediate needs of the medical 
practitioner. Insanity is not a distinct disease, but an abnormal state, 
varying indefinitely in its intensity and separated by no tangible line from 
sanity. Its manifestations are simply alterations, exaggerations, or per- 
versions of the normal faculties, and therefore offer nothing that is abso- 
lutely distinctive. Emotional depression deepens into a pronounced 
melancholia, emotional exaltation lifts itself into the highest mania, 
by insensible gradations, and who shall say where the dividing line is 
between the state in which the man is master of the mood and that in 
which the mood is master of the man ? The insane morbid impulse is 



* Insanity as here defined does not include cases of mental aberration which are 
commonly known in the court-room as insanities, but in which there is a distinct 
organic disease ; in other words, it does not include the so-called Organic or CompU- 
mting Insanities. 



390 



DISEASES OF THE NERVOUS SYSTEM. 



but an exaggeration of that which bids a man standing on the verge of 
some great height to plunge headlong, or which, spreading from breast to 
breast, fills a mob with reckless rage or scatters it in apparently causeless 
panic. 

Insanity being a symptomatic condition and not a disease, it is incor- 
rect to consider its different forms as distinct diseases ; but for the purposes 
of discussion it is necessary to associate cases in symptom-groups to which 
names are given. The naming of these symptom-groups has a distinct 
tendency to lead to the delusion that they are diseases ; hence melan- 
cholia, mania, etc., are continually written about as though they were of 
equal rank with typhoid fever or scarlatina, whereas they are simply 
parallel groups to diarrhoea, paralysis, or dropsy. That they are not 
distinct diseases is shown by the facts — first, that similar mental symp- 
toms may be produced by various organic brain- diseases, and that one 
organic brain- disease will cause, or may cause, antagonistic forms of 
insanity ; thus, in paretic dementia, now there may be a maniacal con- 
dition, now a melancholic one ; second, that not only does every grade 
of case exist in nature, so that acute mania grades into acute melancholia 
without distinct line of demarcation, and cases not infrequently occur 
which may with equal propriety be referred to one or the other of these 
so-called diseases, but also in a single attack of insanity the form may 
change without appreciable cause, so that the patient to-day has mania, 
to-morrow melancholia. 

The insanities included in the definition given above are divided into, 
first, Constitutional Insanities ; second, Pure Insanities. 

CONSTITUTIONAL INSANITIES. 

Definition. — Insanities which are produced by constitutional vice or 
by poisons acting on the whole organism. 

The most important of the constitutional insanities are the toxsemic, 
the lithsemie, the epileptic, and the hysteric. 

The toxcemic insanities are those produced by poisons not formed within 
the body. The only one of sufficient importance to require discussion in 
this volume is that caused by alcohol. For an account of it see the article 
on Alcoholism. For a discussion of epileptic insanity and of hysterical 
insanity, see the articles on Epilepsy and on Hysteria. 

It is well known that lithsemia as well as a paroxysm of acute gout is 
often accompanied by a marked depression of spirits and a peculiar irri- 
tability which may be beyond the control of the sufferer. In some cases 
the mental symptoms amount to an insanity. Moreover, hallucinations, 
delusions, loss of mental power, indeed, almost any conceivable manifes- 
tation of a disordered mentality, may be directly or indirectly produced 
by gout. The true character of such attacks is to be made out by recog- 
nizing the presence of a profound gouty condition, whilst the treatment 
of the case is that for gout, with the superaddition of such narcotics 



FUNCTIONAL NERVOUS DISEASES. 



391 



(chloral, hyoscine, opium, etc.) as may be necessary to keep in check the 
mental disorder and to secure sleep if there be insomnia. In other words, 
the general management of the case is that of the form of insanity simu- 
lated, with the addition of a very active anti-gout treatment. 

PURE INSANITIES. 

Definition. — Insanities which are not dependent upon diathetic con- 
ditions or upon poisons. 

For the purpose of study, these insanities may be divided into two 
groups : 

Functional Insanities comprise those forms or types which are liable 
to occur in individuals who have no distinct original mental warp. 

Neuropathic Insanities are the outgrowths of original vice of brain 
construction ; such vice usually shows its presence early in life in the 
character and mental acts of the individual. 

It must always be remembered, however, that here, as everywhere 
in insanity, our divisions are largely arbitrary, and that in nature cases 
everywhere grade into one another. The varieties of the two insanities 
are as follows : 

Functional Insanities. — Melancholia ; Mania ; Confusional Insanity ; 
Terminal Dementia. 

Neuropathic Insanities. — Constitutional Affective Insanity; Moral In- 
sanity ; Paranoia (Monomania) ; Periodic Insanity. 

MELANCHOLIA. 

Definition. — An acute or chronic functional insanity characterized 
by the dominance of the depressive emotions. 

Symptomatology. — Melancholia usually comes on gradually, with 
insomnia, depression of spirits, malaise, and progressive neurasthenia. 
The characteristic symptom of the disorder is a psychical anguish or de- 
pression, not dependent upon extraneous causes, and so severe as to 
dominate the whole life, so that every perception is painful {psychical 
dysthesia), or all perceptions are flattened down by the absence of desire 
(psychical anwsthesia), or both mental acts and perceptions cause intense 
disgust (psychical hyperesthesia). In the milder forms of the disorder 
there are no loss of the reasoning power and no delusions, the chief symp- 
toms being the great depression and apathy which are produced by the 
subject being absorbed in his own distress and being paralyzed by the 
psychical pain which attends effort. In severer cases there are wringing 
of the hands and perpetual moaning and lamentations. There may still 
be no intellectual aberration, the patient when aroused talking well and 
reasoning well ; but after a time delusions develop which in typical cases 
are unsystematized, and which may exist with or without hallucinations. 
Both hallucinations and delusions are always of the depressive type ; 
the patient hears voices, but they are voices of reproach, of mislead- 



392 



DISEASES OF THE NERVOUS SYSTEM. 



ing, of threatenings. Hallucinations of sight sometimes occur, but are 
less common than hallucinations of hearing ; they are always evil, demons 
of sorrow or woe, perchance lost spirits or avenging angels. Halluci- 
nations of touch are rare, and those of smell are still more uncommon ; 
if they occur, the touch gives pain or disgust, the odor is a sulphurous 
vapor or a horridly fetid exhalation. 

In mild melancholia there may be no distinct sensory disturbances, but 
headache may exist, although more frequently the complaint is of empti- 
ness, of pressure, or of indescribable distress in the head. In the height 
of the disease paresthesia, irregular anaesthesia, and hyperesthesia are 
often present. The most intense suffering is from a peculiar distress, 
referred to the upper chest (precordial anguish), which seems to be an 
exaggeration of the cardiac distress sometimes produced in normal life 
by sudden and overpowering sorrow. Usually occurring in morning 
paroxysms, precordial anguish may happen at any time and continue 
for many hours. The attacks are habitually abrupt, and the agony with 
its accompanying terror may so dominate the consciousness that it is 
obscured or lost in a wild delirium, in which, with a blind disregard 
of himself and others, the patient convulsively attacks and destroys all 
within reach (rcuptus melancholicus), stripping himself naked, breaking, 
smashing, cutting, tearing both persons and things, and perchance dis- 
embowelling himself, twisting off his own genitalia, or in some other way 
committing suicide. During a paroxysm the respiration is rapid and 
superficial, the heart's action irregular and feeble, the skin cool and 
white, and not rarely the paroxysm ends abruptly with a profuse sweat. 

Insomnia is a common symptom, and what sleep the patient gets is 
broken, unrefreshing, disturbed by horrible dreams. The general nutri- 
tion is lowered, the breath foul, the appetite wanting, the urine scanty 
and heavily loaded with urates, oxalates, and phosphates, the muscular 
power greatly lowered. In severe cases there are progressive emacia- 
tion, subnormal temperature, dry cold skin, and cyanotic extremities. 

Simple melancholia has been divided by writers into various forms, 
according to the character of the delusions. Thus, there are Melancholia 
Eeligiosa, in which the delusion is of personal damnation 5 Melancholia 
Hypochondriaca, with hypochondriacal delusions (a form which shades by 
insensible degrees into hypochondriasis) ; and Melancholia Attonita, a very 
severe form, in which the patient passes the time in a condition of par- 
tial or complete stupor, almost motionless and emotionless. In extreme 
cases cerebral action would seem to be completely abolished, but that an 
occasional anxious look, the wrinkling of the forehead, or other slight 
muscular contraction shows that there is still power of thought. In this 
form of melancholia rigidity, muscular contractures, and even catalepsy 
may be present. Sensation may be normal, but there is usually either 
anesthesia or hyperesthesia. 

Melancholia Agitata is a severe melancholia, accompanied by a great 



FUNCTIONAL NERVOUS DISEASES. 



393 



excitement which may rise to a complete frenzy, differing from that seen 
in acute mania in being founded upon intense fear and terror. 

Acute, subacute, and chronic melancholia are constantly spoken of, 
but the terms are arbitrary, there being no distinct forms of the dis- 
order. 

Prognosis. — In melancholia the probabilities of cure are in direct 
proportion to the lightness of the symptoms. About sixty per cent, of 
all the cases get well, usually in periods of from three to twelve months, 
— sometimes after many years. A small proportion of the cases end in 
dementia, and death may take place from complications or even from 
pure exhaustion. 

Treatment. — In the treatment of melancholia the first indication is 
for absolute bodily and mental rest. When there is marked exhaustion, 
without much restlessness, the so-called " rest-cure," in a more or less 
modified form, may be employed ; but, unless the exhaustion be very 
extreme, some out- door life and exercise should be insisted upon. It 
should always be remembered that attempting to argue a patient out of 
his delusions and assertions or to combat his schemes is to excite and not 
to calm. The second indication is to restore as far as possible bodily health 
by meeting any concomitant disease, and by sustaining the bodily power 
by means of properly regulated tonics and nutritious diet. Overfeeding 
should be practised as the rule ; almost invariably the patient should be 
given as much food as the digestive organs will take. The third indication 
is to suppress nervous excitement and induce sleep. Very commonly, 
hyoscine hydrobromate (one-sixtieth to one-hundred-and-twentieth grain) 
may be given regularly at intervals of from eight to ten hours, whilst in 
some instances the similar administration of extract of opium will act 
most happily. At night sulphonal, chloralamide, chloral, and other nar- 
cotics should be used to procure sleep. It is essential that these narcotics 
be given alternately, so as to avoid the danger of chronic poisoning by 
any one of them, and also to prevent, as far as may be, the system from 
becoming habituated to one narcotic. Alcoholic drinks are often of ser- 
vice, but in a long- continued case great moral danger attends their use. 
Prolonged hot baths or hot packs are often very effective in quieting agi- 
tation and procuring sleep. In all cases of melancholia there should be 
the greatest watchfulness against sudden suicidal or homicidal outbreaks. 

MANIA. 

Definition. — Afunctional insanity in which there is great emotional 
exaltation dominating the individual. 

Pathology. — The relations of mania with acute periencephalitis are 
still matters of grave doubt. They will be discussed under the heading 
of acute periencephalitis. 

Symptomatology. — Acute mania may be developed suddenly or be 
preceded by a prodromic stage of emotional depression lasting from a 



394 



DISEASES OF THE NERVOUS SYSTEM. 



few days to several months, during which time the symptoms resemble 
those of a mild melancholia. When the maniacal stage is reached, emo- 
tional excitement develops rapidly, delusions and hallucinations appear, 
and in bad cases the patient raves incessantly, shouting out a perpetual 
stream of incoherent threatenings, revilings, obscenities, and blasphemies. 
There are pronounced loss of sensibility, almost complete insomnia, great 
sexual excitement, incessant activity, the patient rushing about his apart- 
ment, struggling with his attendants or mechanical restraints, destroy- 
ing clothing, bedding, etc., smearing his excrement over his person, and 
passing whole days and nights in a fury. The maniac has great mus- 
cular strength and endurance, and abundant appetite ; but progressive 
loss of bodily weight usually occurs in spite of the enormous quantities 
of food apparently digested. The temperature is often somewhat higher 
than the norm, but rarely reaches 100° F. 

In the mildest forms of acute mania, incoherence, irrationality, rest- 
lessness, hallucinations, and delusions, with marked insomnia and total 
loss of modesty, may be the only symptoms. Hypoynania is a form of the 
disorder corresponding to the mildest cases of melancholia ; in it there 
are no hallucinations or delusions, but only a condition of emotional 
exaltation with a change of character, a peculiar egotistic hilarity, per- 
petual extravagances, restlessness, and increased sexual appetite with 
lessened control of the will-power, leading to great sexual excesses and 
a tendency to brutal violence. 

Prognosis. — Recovery may occur in a few days, but usually it is 
delayed from three to six months or even longer. Death takes place in 
about ten per cent, of the cases from exhaustion ; in about twenty per 
cent, the mental aberration passes into chronic mania. 

Chronic Mania. — Chronic mania may develop from acute mania or 
come on gradually. It is characterized by incoherence of speech, lack 
of power of association of ideas, delusions, often increased activity of 
the perceptive faculties with hallucinations, and mental and physical 
excitement. Both in acute and in chronic mania the delusions are unsys- 
tematized. In most cases of chronic mania there are intermissions in 
which the symptoms are much less severe. Recovery rarely occurs ,• 
usually, by a progressive failure of the intellectual power, the patient 
drifts into terminal dementia ; not rarely chronic mania changes into 
chronic melancholia. 

Treatment. — The indications for treatment in acute mania are to 
support the patient and to quiet the nervous system : any antiphlo- 
gistic or reducing measures do great harm. Hyoscine hydrobromate is 
the most valuable of all the calmatives, but chloral, sulphonal, codeine, 
conium, and other narcotic drugs must be used to procure quiet and 
sleep. Counter-irritation, in the form of blisters to the scalp and the 
nape of the neck, may be used, but rarely accomplishes much good. Hot 
baths and packs are sometimes serviceable. 



FUNCTIONAL NERVOUS DISEASES. 



395 



CONFUSIONAL INSANITY. 

Definition. — An acute functional insanity without distinct constant 
emotional depression or exaltation, with, marked abatement of mental 
power, often, but not invariably, accompanied by hallucinations and 
great mental excitement. 

Synonymes. — Primary curable dementia ; Stuporous insanity ; De- 
lusional stupor ; Mania hallucinatoria ; Surgical insanity ; Puerperal 
mania ; Post-febrile insanity ; Mania following typhoid and other acute 
fevers. 

Etiology. — Great emotional strain or shock, severe surgical opera- 
tion, childbirth, various acute diseases (such as rheumatism, typhoid 
fever, diphtheria, epidemic influenza), famine, starvation (especially 
when accompanied by hardships), may any of them be the cause of 
confusional insanity. 

Pathology. — The underlying condition of confusional insanity ap- 
pears to be a peculiar exhaustion of the cerebral cortex. The most 
careful microscopic examinations by thoroughly capable observers have 
proved that there is no demonstrable congestion or inflammation of the 
brain cortex, and thus far no one has been able to detect any characteris- 
tic changes in the ganglionic cells of the brain. 

Symptomatology. — In extreme cases of confusional insanity* (Pri- 
mary Curable Dementia) there is almost complete paralysis of all the func- 
tions of the brain cortex, so that the patient remains in a condition of 
more or less pronounced stupor or stupidity, with progressive loss of 
weight, great reduction of the muscular strength, a feeble, small, quick 
pulse, and various shifting kaleidoscopic anomalies of vaso-motor inner- 
vation, such as wandering cedematous swellings. All the reflexes and 
the sensibilities are diminished, the pupils react feebly and slowly, the 
bodily temperature is subnormal, the urine is scanty and loaded with 
phosphates. 

In milder cases of confusional insanity (Hallucinatory Insanity) there 
is depression of consciousness or of emotion shown in a peculiar quietude 
or apathy, — replaced by stupor in more severe cases. An almost char- 
acteristic symptom is the peculiar mental confusion, which may show 
itself in the inability of the patient to talk coherently and consistently 
or to follow out any train of thought, or may be so pronounced that the 
subject fails to recognize his friends or his surroundings. Along with 
these symptoms of mental failure there are frequently extraordinary 
and vivid hallucinations, so that the patient is unable to distinguish 
between subjective and objective sensations, realities and imaginations 
being intermingled in his consciousness into a hopeless chaos. The 
delirium of confusional insanity may counterfeit that of acute mania, 

* There is a rare form of confusional insanity, ending in death, simulating acute 
periencephalitis. See article Acute Periencephalitis. 



396 



DISEASES OF THE NERVOUS SYSTEM. 



the patient being perchance violently erotic or excessively aggressive ; 
the aggressiveness, however, probably always rests upon the foundation 
of fear, the patient making the assault in self-defence, — that is, with the 
idea of protecting himself from an enemy. 

The physical conditions of confusional insanity are always those of 
feebleness and exhaustion ; the temperature disturbances in severe cases 
are pronounced, there is usually either an habitually low temperature or 
a marked tendency to paroxysms of subnormal temperature, with in many 
cases very pronounced febrile reactions ; the swing of the temperature is 
remarkable for its irregularity and its activity. 



Fig. 2. 




21 i 22 I 23 I 24 ! 25 26 I 27 1 28 I 29 ! 30 1 31 i r J 2 1 3 ' 4 • 



Temperature curve of a ease of confusional insanity. The figures at the bottom represent the days 
of the month, beginning with May 21. 

Diagnosis. — In most cases the true nature of confusional insanity is 
easily recognized. The history of the outbreak having been preceded 
by an exhausting disease, by famine, by traumatism, by emotional shock, 
the failure of bodily nutrition, the general depression of muscular and 
nerve force, the absence of dominating emotional excitement, the ten- 
dency to apathy or stupor, the peculiar mental confusion, the shifting 
character of the hallucinations and delusions, — all these form a picture 
which resembles that of no other disease. 

Prognosis. — The prognosis in confusional insanity, provided there be 
no pre-existing bodily lesion, such as unsound kidneys and degenerated 
arteries, is highly favorable. Krafft-Ebing gives the recovery at seventy 
per cent. ; in our practice the proportion has been even larger. The 
recovery is usually complete, but the mental powers may be enfeebled ; 
there is never a reasoning insanity nor a state resembling that of para- 
noia produced. When the attack has been caused by a very sudden and 
overwhelming emotion and the mental powers are completely lost, the 
outlook is very grave. 

Treatment.— In confusional insanity the treatment should be carried 
on outside of an insane asylum, unless the pecuniary position of the 
patient makes it impossible to get a sufficient supply of trained nurses, etc. 
The great indication is for support ; there is usually no appetite, but the 
powers of digestion are commonly much better than they seem, so that 
forced feeding is well borne. The most nutritious food, especially milk 
and raw eggs, should be given at intervals of two or three hours, in as 



FUNCTIONAL NERVOUS DISEASES. 



397 



large quantities as the stomach will tolerate. It is essential that the bodily 
warmth of the patient be maintained and sudden failures of temperature 
and collapse guarded against. External heat, by means of the hot- water 
bed, or bags of hot water, or the hot bath, should be used whenever the 
temperature falls below 97.5° F. In bad cases the rest must at first be 
absolute ; even massage increases the exhaustion. Later in the treatment, 
massage and electrical stimulation of the muscles may be of great service. 
During convalescence the best results are sometimes obtained by removing 
the patient to the sea-shore, mountains, or other places of resort 5 but all 
over-exertion must be avoided. Drugs are used — first, to increase the 
nutrition, especially of the nerve-centres 5 iron combined with bitter tonics 
in small doses, strychnine given in ascending doses to the limit of physical 
tolerance, and phosphorus continually exhibited in such small doses (y^ to 
of a grain) as not to disturb the digestion, are the best remedies : 
second, to quiet delirious excitement and to obtain sleep ; the bromides 
are to be avoided, as they not only depress the functions but probably 
also the nutrition of the cortical cells of the brain ; hyoscine is of great 
value, cannabis indica may be essayed, and chloral, sulphonal, and opium 
may be useful as hypnotics. Sometimes an acute delirium yields to blis- 
tering of the scalp. The bowels should be kept free, but there should be 
no purgation. 

TERMINAL DEMENTIA. 

Almost any acute insanity may be followed by a chronic condition 
of mental weakness having no distinctive characteristic of the original 
insanity. The completeness of the mental ruin varies indefinitely. In 
some cases the individual is little more than a vegetating automaton ; in 
other instances the dement is restless, full of obtrusive or destructive 
activity, overflowing with animal spirits, possessed, it may be, by a pecu- 
liar egotism, but useless for any purpose requiring consecutive action. 
Again, in some cases there is a childish weakmindedness. No medical, 
hygienic, or moral treatment is of any avail. 

NEUROPATHIC INSANITIES. 

Insanity, nervous diseases, syphilis, poverty and the lack of the neces- 
sities of life, dissipation, excessive luxury, —these and other similar active 
causes in the parent lead to degradation in the offspring ; whilst the mul- 
titudinous ills which are possible to the young life, especially in the midst 
of extreme poverty, act upon the child itself, so that there is a peculiar 
degradation of mental development or failure of development of the nerve- 
cenl res which produces a peculiar constitution known as the neuropathic 
and furnishing root-stocks from which spring criminals, lunatics, and 
a multitude of beings of whom the world wonders whether they should 
be considered sane or insane. Space is wanting to speak further of this 
subject ; suffice it to say that these children of degradation may have 



398 



DISEASES OF THE NERVOUS SYSTEM. 



great intellectual power, and that it is impossible in many instances to 
decide how far the individual should be considered legally responsible 
for his acts. In common with most alienists, we believe that there are 
neuropathic subjects who should be considered insane although they have 
no actual delusions, and that these cases may be divided into two groups : 
first, Eeasoning Insanity ; second, Moral Insanity. 

In reasoning insanity there may be cases with emotional exaltation and 
emotional depression corresponding to mania and melancholia. In this 
class are included those persons who suffer from imperative conceptions 
or morbid impulses. (See page 385.) It must be remembered that the 
sequence of cases from eccentricity to reasoning insanity without de- 
lusions, and from reasoning insanity without delusions to paranoia, is 
unbroken. 

Moral lunatics are those who are not only devoid of a conscience but 
are actually driven by their natures to what seem to others horrible 
crimes. Among the moral insanities must be classed the so-called sexual 
perversions, which may be due to long-contined vice, but which may be 
congenital. 

PARANOIA. 

Definition. — Neuropathic insanity with more or less pronounced 
systematized delusions and without cyclical changes. 

Symptomatology. — Paranoia may come on abruptly, but it usually 
develops slowly out of a character which from the very beginning of 
life has shown evidences of neuropathy, especially in its morbid egotism. 
Its course is essentially chronic, but frequently there are intermissions 
which may last for months and which sometimes seem to be almost com- 
plete. Exacerbations are also liable to occur, taking the form of stupor- 
ous dementia, or of violent hallucinatory delirium, or of a fierce mania. 
Paranoia very rarely ends in complete dementia, but rather in a condition 
of psychical weakness and good-natured stupidity, through which may be 
preserved in part the artistic or technical abilities originally possessed 
by the subject. 

Paranoia may be divided into two forms, according to the time of its 
development. When it appears about puberty it constitutes the hebe- 
phrenia of authors. This psychosis frequently begins with symptoms 
of mild melancholia, with apathy and an hysterical desire for sympathy ; 
in a great majority of cases the subjects are excessive masturbators. 

Late paranoia may not appear until past middle life. In its most 
common form it is attended with delusions of persecution : at first the 
subject feels that the world is becoming hostile, then suspicion attaches 
in his mind to certain individuals or groups of individuals, and increases 
until it becomes a fully formed delusion, the paranoiac knowing that he is 
the object of persecution, but the form of persecution varying in his mind 
according to his environment. Usually the delusions have a sexual 
tinge, one of the most common being the belief that the wife or the hus- 



FUNCTIONAL NERVOUS DISEASES. 



399 



band is unfaithful. About the time when the delusions become fixed, 
hallucinations appear ; those of hearing are most frequent, but any one 
of the special senses may be involved. The emotional state is one of 
depression, but this depression is essentially different from that of mel- 
ancholia, for, whilst the victim of melancholia believes himself deserving 
of his sorrow, to himself exaggerates his guilt and his humiliation, the 
paranoiac, depressed though he may be by his persecutions, knows that 
these persecutions are unmerited and rebels against them. Not infre- 
quently, either in self-defence or to revenge himself for wrong, or per- 
chance simply goaded into fury by a sense of injustice, the paranoiac 
assaults his fancied persecutor. In very many cases he continually 
attempts to assert his rights through the law. 

A second form of paranoia is that in which the delusions take a re- 
ligious form ; this madness almost invariably has blossomed out from 
an early character of excessive piety, and often ends in a condition of 
religious ecstasy, sometimes alternating with states of depression. A 
third form of paranoia is that which has already been spoken of under 
the name of erotomania. 

PERIODICAL INSANITY. 

Definition. — A neuropathic insanity in which the attacks come on 
at regular or irregular intervals. 

Among the periodical insanities may be mentioned the so-called Men- 
strual insanity, in which the attacks return at the menstrual period ; 
Mania periodica, in which there are periodical attacks of acute mania ; 
and Melancholia periodica, a very rare disease, in which during the par- 
oxysms the symptoms are those of ordinary melancholia with usually 
extraordinarily active suicidal impulses. 

Certain cases with imperative conceptions or morbid impulses also 
belong among the periodical insanities. Thus, there have been instances 
of periodical kleptomania, pyromania, sexual perversion, dipsomania, 
etc. 

In Circular Insanity, or Cyclothymia, the symptoms follow a more or 
less regular cycle through life. A melancholia may be followed by a 
mania and then by a lucid interval, which ends in a recurring melan- 
cholia, and so on ; or mania may begin the cycle, or the lucid interval 
may occur between the melancholia and the mania. There are no 
synrptoms which separate the stages of a cyclical insanity from a sim- 
ilar mental condition having other causes : so that the diagnosis must 
rest on a knowledge of the existence of the cycle. 

Treatment. — Neuropathic insanities have no specific treatment ; 
being ingrained, they are usually incurable, and require moral manage- 
ment, maintenance of the general health, and often restraint. The 
greatest care is necessary in the use of narcotics lest the narcotic habit 
be formed. 



400 



DISEASES OF THE NERVOUS SYSTEM. 



NEURASTHENIA. 

Definition. — A condition of lack of power of the nerve-centres, not 
dependent npon the existence of organic disease in any portion of the 
body. 

Etiology. — Primary neurasthenia very commonly has for its predis- 
posing cause an original feebleness of constitution of the nervous system. 
It may be produced by overwork, especially when this overwork is com- 
bined with emotional strain. As the endurance of human individuals 
varies almost indefinitely, overwork, as just used, is a relative term, 
meaning that the daily expenditure of nerve-force is greater than the 
daily income. 

Morbid Anatomy. — There is no recognizable change in the nerve- 
centres in neurasthenia. In many cases, undoubtedly, there is a peculiar 
vaso-motor weakness in these centres, which makes them exceedingly 
liable to congestions, as well as an exhaustion of the nerve- cells them- 
selves. 

Symptomatology. — Neurasthenia may be local or general. Very 
frequently a local neurasthenia precedes the development of a general 
neurasthenia. Thus, a cerebral asthenia the result of mental overwork, 
or a sexual spinal asthenia the result of sexual excesses, may exist by 
itself, but in most cases the local weakness is soon followed by a general 
neurasthenia. Usually neurasthenia develops slowly, but it may develop 
abruptly. The symptoms vary in accordance with the portion of the 
nervous system most affected. They may be generalized as a loss of 
power of performing functional acts, associated with great irritability. 
Thus, loss of power of fixing the attention, slight weakness of memory, 
disturbance of sleep, sense of weight and contractions in the head, tin- 
nitus aurium, asthenopia, depression of spirits, great distress on mental 
effort, are the usual manifestations of a brain -exhaustion, whilst failure 
of muscular power, of endurance, of sexual power, of vaso-motor power, 
of control over circulation and calorification, result from weakness of 
the lower nerve-centres. 

In neurasthenia the vaso-motor symptoms are often pronounced. Ex- 
cessive blushing on the slightest provocation or on the use of alcohol, cool 
extremities, occasional pallors, excessive sweating, especially at night and 
during sleep or during emotion or excitement, are ordinary symptoms. 
The heart is often very irritable, palpitation, shortness of breath, and 
exaggerated increase of the pulse upon exertion being usually present. 
Irregularity and intermission of the pulse are especially frequent when 
the subject has the tobacco habit or there is gastric irritability. Apical 
systolic murmurs are often present when there is no decided ansemia or 
cardiac disease. In most cases there is, at times, subnormal temperature, 
and not very rarely the daily range is from one to two degrees of tem- 
perature below 98.5° F. A very large proportion of neurasthenics are 



FUNCTIONAL NERVOUS DISEASES. 



401 



lithsemic and suffer much from neuralgia. Atonic dyspepsia, disordered 
hepatic function, and constipation or diarrhoea are often the result of 
the improper innervation of the digestive organs. 

Diagnosis. — The only difficulty connected with the diagnosis of neur- 
asthenia is the danger of mistaking a primary neurasthenia for one 
dependent upon the presence of stomachic, intestinal, renal, or other 
organic disease. It is essential in every case that the examination for 
local or constitutional disease be rigorously complete. 

Prognosis. — The prognosis in neurasthenia depends chiefly upon how 
far the condition is dependent upon original constitutional feebleness. 
The more severe the symptoms and the more slow their development, the 
greater the length of time required for their relief. 

Treatment.— In nervous exhaustion recovery can be obtained only 
through rest and food, aided by the use of remedies for stimulating 
nutrition. Minor disagreeable symptoms may be met as they arise by 
drugs. Strychnine, arsenic, and phosphorus given for a length of time 
are often of service as alterative nutrients, but the chief reliance must be 
upon hygienic treatment. 

Local neurasthenia, whether existing by itself or as the foundation of 
a general neurasthenia, requires rest of the organ primarily worn out. 
Thus, in sexual neurasthenia sexual abstinence is absolutely essential. 
In brain-tire it is the brain which must be rested. To rest an over- 
wearied, excited brain is often not an easy task. In attempting it the 
effort should be to obtain the following results : first, the removal of 
all cares, anxieties, and brain- work, especially brain-work of such char- 
acter as has been connected with the break- down ; second, the mainten- 
ance of the interest of the patient, so that the past shall for the time 
being be forgotten and the present not be overweighted with irksome- 
ness ; third, invigoration of the physical health of the whole body, and 
especially of the nervous system. In order to obtain the first of these 
measures of relief, isolation of some sort is essential ; for the second, 
mental occupation is usually required ; for the third, fresh air, exercise, 
or some substitute is to be superadded to abundant food and rest. 

The proper method of meeting these indications varies greatly, not 
only with the varying physical conditions and idiosyncrasies of patients, 
but also with their diverse domestic and pecuniary relations. To give 
detailed directions for every case is impossible, and we shall therefore 
limit ourselves first to simple cases of brain-tire in which the muscular 
strength is preserved ; second, to cases of profound general neurasthenia. 

In brain-tire travel is usually recommended, and travel affords, when 
properly directed, separation from old cares and thoughts, a maintenance 
of interest by a succession of novel sights and experiences, and the phys- 
ical stimulation of fresh air and exercise. In bad cases general travel 
is too stimulating. Ocean- voyaging gives complete isolation, fresh air, 
mental stagnation, and, if the patient be fond of the sea, complete enjoy - 

20 



•402 



DISEASES OF THE NERVOUS SYSTEM. 



nient. Camping in the wilderness offers also all these advantages, and 
as a farther good the possibility of obtaining exercise in exactly the 
amount desired. The subject may live in his tent and be nursed and fed 
by his guide, or may do the work of a day-laborer. Quiet travel in the 
mountainous districts of foreign countries is often very efficient, but 
sight-seeing, and even visits to cities, must be avoided. The quiet of 
Switzerland or of the Tyrol may bring restoration when the bustle of 
London and Paris might complete the ruin. In all cases strict attention 
must be paid to the individual tastes of the sufferer in deciding what 
measures should be carried out. 

There are cases of neurasthenia in which the slightest exercise, or 
even the unconscious effort and excitement of seeing personal friends, 
will do harm. In these cases the so-called "rest-cure" often acts most 
beneficially. It rarely gives permanent relief, but often lays the founda- 
tion for an eventual restoration by means of out- door life and exercise 
taken after a certain amount of strength has been gained. A word of 
caution seems necessary against the routine employment of this rest- 
cure. It is simply the carrying out of a principle, and, although in the 
pages of a book like this it is necessary to give a fixed formula, suc- 
cess iu practical life will depend upon the skill of the practitioner in 
modifying this and adapting formulae to the needs of the individual 
case. The principles of the rest-cure are absolute rest, forced feeding, 
and passive exercise. The rest must be for the mind as well as for the 
body, so that in severe cases complete and absolute isolation must be 
insisted upon ; and especially when there is a decidedly hysterical ele- 
ment is it necessary to separate the patient entirely from her friends. 
Under these circumstances there must be a well-trained nurse who is per- 
sonally agreeable to the patient. The confinement would be very irksome 
to any except the most exhausted patient were it not for the daily visits of 
those engaged in the treatment. Further to provide against ennui, the 
nurse should be a good reader, so that under the definite instructions of 
the physician she can occupy a certain portion of the time in reading to 
the patient. In the worst cases the patient should not feed himself or 
herself or perform any of the acts of the toilet. Directly after break- 
fast the sponge-bath should be given by the nurse, the patient being 
between blankets. Hot water should be used, or hot sea-brine, and after 
each part has been sponged over it should be momentarily rubbed with 
a piece of ice, followed by brisk friction with a Turkish towel. The 
greatest care should be given to the question of feeding. The end to be 
attained is to give as much food as can be digested, without deranging 
the digestion by overfeeding. It is usually better to give the food, which 
must be both light and nutritious, at short intervals. In most cases milk 
should be used very largely, sometimes exclusively. Often, especially 
when there is a tendency to obesity or when the digestive powers are 
feeble, the milk should be skimmed. Frequently koumiss, matzoon, or 



FUNCTIONAL NERVOUS DISEASES. 



403 



other fermented milks are agreeable to the palate and stomach. More 
rarely peptonized milk is serviceable. Beef and other concentrated 
meat-essences are valuable as stimulants, and may be used especially as 
the basis of soups. Various farinaceous articles of food may be added 
to them, or if an egg be broken into the concentrated bouillon or beef- 
essence just as it ceases boiling, a nutritious and, to many persons, 
palatable dish is obtained. When constipation exists, oatmeal porridge, 
Graham bread, and fresh or dried fruits may be allowed if readily digested 
by the patient. In order to give a general plan of the dietary the fol- 
lowing schedule of the daily life is appended. Such a schedule should 
always be put into the hands of the nurse, who should be required to 
follow it strictly. It must be so altered from day to day as not to weary 
the patient with monotony. It is especially important to remember that 
the diet must be carefully studied for each patient and be adapted to the 
individual requirements of the case. Success will in a great measure de- 
pend upon the practical skill and tact of the physician in this adaptation : 

8 a.m. Eolls or toast ; cocoa, weak coffee, or roasted wheat coffee; 
beefsteak tenderloin or mutton chop. 

9 a.m. Bathing. 

11 a. m. Oatmeal porridge or wheatena with milk, or a pint of koumiss. 

12 m. Massage. 

2 p.m. Dinner : bouillon with or without egg ; beefsteak ; rice ; roast 
white potatoes ; dessert of bread-pudding, blanc-mange, or a similar 
farinaceous article of diet. 

4 p.m. Electricity. 

5 p.m. Milk toast. 

9 p.m. Half- pint of skimmed milk or koumiss. 

In many cases the patient at first can take very little food, and it is 
very frequently best to begin the treatment with an entirely liquid diet, 
giving milk every two hours or using Liebig's raw- meat soup, with milk 
or plain farinaceous food, and only after a time gradually accustoming 
the patient to solid food. Not rarely a prolonged milk- diet is of great 
service. The rest-cure is indeed largely based upon a careful regulation 
of the food ; but a full discussion of the various dietaries to be used would 
require a treatise upon dietetics. 

Exercise is of value in health by its stimulating the general nutrition, 
aiding the flow of blood back to the heart, and increasing the excremen- 
titious output from the emunctories. In the rest-cure these effects are 
obtained in a more or less imperfect manner without the expenditure 
of the patient's nerve-force by the use of electricity and massage. The 
electrical current not only produces muscular contractions, but probably 
affects the tone of the minute blood-vessels. Its action is so decisive 
that, as has been shown by Dr. S. Weir Mitchell, it will often tempo- 
rarily elevate the temperature of the whole body. The faradic current 
alone is used. It is applied in two ways : first, to the individual nius- 



404 



DISEASES OF THE NERVOUS SYSTEM. 



cles ; second, to the whole body. The seances should be daily, the 
operator beginning at the hand or foot and systematically faradizing each 
muscle of the extremities and trunk. The slowly interrupted current is 
generally preferable, but advantage is sometimes gained by varying the 
rapidity of the interruptions. The rule is to select that current which 
produces most muscular contraction with the least pain. The poles 
should be applied successively to the motor points of the muscles, so 
that each muscle shall be made to contract firmly and thoroughly. This 
process should occupy from thirty to forty minutes. The electrodes are 
then to be replaced by large sponges well dampened with salt water : one 
of these should be placed at the nape of the neck and the other against 
the soles of the feet, and a rapidly interrupted current, as strong as the 
patient can bear, should be sent through the body for twenty minutes or 
half an hour. In some cases the electrical programme may be so varied 
as to get a local stimulant action from the general current : thus, when 
the digestion is enfeebled and the bowels are costive, for a portion of the 
time one of the sponges may be placed upon the epigastric region. In 
women, when there is great abdominal and pelvic relaxation, one pole may 
be placed high up in the vagina. We have seen moderate long-standing 
uterine prolapse cured in this way. Some electro -therapeutists hold that 
great advantage may be obtained by galvanizing the cervical sympathetic 
ganglia, but we do not believe that these ganglia can be reached by cur- 
rents of therapeutic strength. 

Massage, like electricity, affects greatly the peripheral circulation, 
empties the juice- channels, and gives tone to the muscular system. It 
must be clearly distinguished from rubbing of the skin. It consists in 
manipulations of the cellular tissue and of such of the muscles as are not 
too deep to be reached. In order to lessen as much as may be the skin- 
friction by these manipulations, it is often well to anoint the surface with 
the oil of cocoa-nut or other bland fat. In practising massage it is essen- 
tial to remember that the natural course of the venous blood and the 
lymph is towards the centre of the body ; therefore all general mas- 
sage movements should be practised in this direction. The manipu- 
lations are percussion, rolling, kneading, and spiral. They consist of 
movements made with the pulpy ends of the fingers and thumbs, and 
spiral movements with the whole hand so folded as to adapt its palm to 
the limb. In percussion the strokes should be from the wrist, and should 
be quick and short. It seems hardly possible, even by long, strong 
strokes, to affect the deepest muscles. In the rolling manipulations the 
effort is to roll the individual muscles beneath the pulps of the fingers. 
This manipulation may be varied by pinching the muscles, not the skin, 
and kneading them. In each case the aim should be that of intermittent 
pressure upon the muscles. The circular movements are to be in opposite 
directions with both hands simultaneously, the limb being grasped by one 
hand a little above the other, and a spiral sweep made up the limb, the 



FUNCTIONAL NERVOUS DISEASES. 



405 



ball of the thumb and the palm of the hand resting upon the patient, 
and the pulpy parts of the thumb and the fingers grasping the limb. It is 
especially such motions as these that affect the circulation of the lymph. 

The length of time for which a patient should be kept in bed varies 
from three to six weeks. The getting up should be gradual, the time 
of sitting up and the amount of exercise being carefully increased from 
day to day. The electrical treatment should be rapidly withdrawn, but 
massage may often be continued with advantage every other day for some 
time. So soon as may be, the patient should be sent out of the city, to 
consolidate by out- door life that which has been gained. 

HYSTERIA. 

Definition. — A functional nervous disorder, characterized by de- 
pression of the will-power and of the inhibitory functions of the nervous 
system in general, and by increased emotional activity and sensibility, 
with an infinitude of shifting polymorphic nervous disturbances. 

Etiology. — The hysterical temperament may be a congenital form 
of neuropathy, or it may be produced by luxury, license, over-indulgence, 
a lack of out- door life and active exercise, etc., during childhood or early 
life. It has no direct relation with the sexual organs, but is frequently 
the result of the exhaustion produced by sexual excesses, especially in 
the young. In boys it is often caused by masturbation. Climatic influ- 
ences affect greatly the development of the hysterical temperament, which 
is much more abundant among the French and Italian than among the 
Anglo-Saxon and Teutonic races. Hysteria may be developed in persons 
who have no distinct hysterical temperament by overwork, depressing 
emotion, long- continued severe pain, or the exhausting depression of 
disease. It is psychically contagious, so that a single hysterical individual 
will affect a whole school or ward. During the Middle Ages, when by 
misery, poverty/ and religious excitement the ground had been especially 
prepared, whole communities became involved in this way in epidemics 
of religious madness : hence the Flagellants, Children's Crusade, etc. 

Morbid Anatomy. — There is no anatomical peculiarity of the nervous 
system in the most profoundly hysterical person that can be recognized, 
and space cannot here be afforded to discuss the numerous theories of 
the disease which have been suggested. 

Symptomatology. — Hysteria exists in almost every possible degree, 
and the variations of symptoms are so infinite that the only method 
practicable in a brief space is not to attempt any description of the 
disease, but to discuss under separate headings the separate symptoms 
or classes of symptoms. In ingrained hysteria there are usually certain 
physical peculiarities which at least suggest to the observer the tem- 
perament, such as the large, full, liquid eye with mobile pupil, especially 
when associated with a brilliantly clear skin and with the ever-changing 
whims or the slow, languid movements of self-consciousness. 



406 



DISEASES OF THE NERVOUS SYSTEM. 



Hysteria is practically divided into the minor and the major disease, the 
latter comprising cases in which there are violent epileptic attacks with 
automatic manifestations. Major hysteria is rare among Anglo-Saxons in 
either continent ; whilst in the extreme southern United States, peopled 
by the Latin race, it is said to occur as frequently as it does in France. 

Mental Symptoms. — The basis of the hysterical character is selfish- 
ness, which shows itself rather in the overmastering desire to be the centre 
of sympathy and admiration than in the indulgence of grosser appetite. 
The hysterical woman is self-conscious and self-centred, always occupied 
with her own needs and wishes. The will is also weak, the emotional 
nature extremely sensitive, and the tendency to impulse pronounced, so 
that the individual is almost devoid of self-control. Emotional instability 
and lack of control over the emotional nature by the will are two of the 
most characteristic manifestations of the hysterical state. With or with- 
out reason the patient laughs and cries, and, perchance on the slightest 
provocation, passes into the most violent paroxysms of laughter or of 
weeping, whose nature is recognized by every one. The morbid desire for 
attention and sympathy, joined with the extraordinary importance to the 
subject of everything that pertains to his or her personality, leads always 
to great exaggeration of symptoms, and not rarely to intentional simula- 
tion of disease. Especially common is it for the simulated symptoms to 
take the shape that will bring great personal attention on the part of the 
young and inexperienced physician and mayhap minister to the morbid 
sexual desires of the patient. To swallow pins and needles and to thrust 
them into the tenderest parts of the body, to fill the uterine cavity over- 
night with the bones of small animals, to distend the rectum with foreign 
bodies or with starch-jellies, to retain the urine with absolute recklessness 
of the suffering involved, — all in order that the person may be talked 
over and worked with by the doctor, — are common arts among hysterics. 

In hysteria not only purposed but also unconscious simulation of 
disease is very frequent, the unconscious simulation being largely, if 
not altogether, the effect of an idea formed in the mind. The dread 
of some disease, a suggestion from the doctor himself, the sight of a 
peculiar symptom in some one who is really ill, may be as powerful as is 
wilfulness in multiplying the symptoms of an hysteric. 

The confirmed hysterical temperament belongs among the neuropa- 
thies, and the mental condition in its highest development resembles 
that of the paranoiac, and is almost as incurable. Moreover, like the 
paranoiac, the hysteric is liable to explosions which may take the form 
of a violent acute mania or of a deep melancholia ; indeed, hysterical 
mental disturbances may simulate any form of insanity, so that the diag- 
nosis of the true nature of such a case must rest upon the previous his- 
tory of the patient. 

Disturbances of Consciousness and Motion.— Spasms, tremors, 
clonic movements, and paralysis in all forms and degrees are very 



FUNCTIONAL NERVOUS DISEASES. 



407 



common in hysteria, but besides these motor disturbances there are con- 
vulsive paroxysms with or without characteristic phenomena. In major 
hysteria the convulsion is usually but not invariably preceded by some 
warning, and it may be by a distinct aura. The patient generally falls 
gently, not abruptly as in true epilepsy, often with an initial scream ; 
the face is pallid. The spasm is at first tonic, with arrest of respiration, 
which may continue until the swollen, turgid face indicates imminent 
suffocation. In from two to three minutes a furious clonic convulsion 
occurs, with bloody foam about the mouth, the movements preserving, 
however, to some extent the appearance of wilfulness, and the head and 
arms being dashed with seeming purpose against surrounding objects. 
The clonic convulsion is in a very short time followed by the character- 
istic stage of opisthotonos, in which the body is bent so violently into 
the arc of a circle that it rests upon the head and feet, or in severe 
cases upon the toes and the face, which latter from the excessive retrac- 
tion of the head looks towards the floor, — i.e., behind the body. Opis- 
thotonos is by and by replaced by violent purposive clonic spasms, the 
patient suddenly leaping from the bed or rising into a sitting position, 
and as quickly falling back again into opisthotonos. This to-and-fro 
movement may occur with extraordinary velocity. The opisthotonic 
stage finally subsides or is suddenly interrupted by the emotional stage, 
when the patient assumes an attitude of intense emotion, not rarely the 
so-called posture of the crucifix, with outstretched arms and legs and 
widely opened eyes, dilated pupils, and an expression of intense religious 
ecstasy. Usually emotion changes from time to time ; religious joy gives 
way to an intense voluptuousness, or to an outburst of terror, or to a 
passion of penitence, and so, now singing, now weeping, now rejoicing, 
now reproaching, the subject passes into a slowly perfected consciousness. 
Very commonly during the paroxysms there are hallucinations whose 
character corresponds with the emotional state. 

Any one of the stages of the major hysteria just spoken of may be 
omitted, or may constitute the whole of the paroxysm. 

In the so-called minor hysteria there is usually no distinct aura, but 
very commonly in the beginning a globus hystericus (a sense of constric- 
tion or of the rising of a ball in the throat). The emotional disturbance 
is generally well developed, and is prone to express itself by uncontrol- 
lable laughter or equally uncontrollable sobbing or crying. Clonic con- 
vulsions may occur, but the contractions are usually tonic, and more 
or less pronounced ; wide-spread muscular rigidity is a very frequent and 
very characteristic phenomenon. Under certain circumstances the hys- 
terical paroxysms take on peculiar features. A form which we have seen 
especially among children is beast mimicry, in which the patient bites or 
snaps or snarls like a dog, or crows like a cock, or in some other way 
imitates the movements and sounds of the lower animals. In spurious 
hydrophobia, with symptoms simulating those of the true disease, the true 



408 



DISEASES OF THE NERVOUS SYSTEM. 



character of the attack is always revealed by the snarling, the barking, 
and the attempts at biting, which do not occur in true hydrophobia. 

Hysterical somnolence may take the form of a narcolepsy (the subject 
being continually drowsy, but passing only the nights in profound slum- 
ber) or of a lethargy or trance. Hysterical trance usually, but not always, 
commences with marked hysterical symptoms. In the early days of the 
attack the face may be red and hot, the pulse regular and slow, and the 
bodily temperature somewhat elevated. Later, there is pallor of the face, 
with rapid feeble pulse, the respiration is above the norm in number, or so 
nearly abolished that the movements of the thorax can scarcely be traced, 
the muscular system is thoroughly relaxed, the eyes are open or closed, 
and the pupils are dilated. There may also be complete anaesthesia, — so 
that neither bright lights, nor loud sounds, nor pinching, nor cold, nor 
heat, will elicit response, — scanty or almost suppressed urine, protracted 
constipation, and a subnormal bodily temperature. In the most extreme 
cases the appearance is that of a corpse ; the pupils are immovable and 
the cornea filmy, and it may be that no motion can be detected in the 
heart or chest, so that in many instances death has been announced to 
have taken place. In some cases of hysterical trance there is great mus- 
cular rigidity, with set jaws, or periods of rigidity may alternate with 
periods of relaxation. 

Catalepsy is a form of hysterical lethargy characterized by a peculiar 
condition of the nervo-muscular apparatus which causes the body or the 
limbs to remain almost indefinitely in any position in which they may be 
placed. There is no power of voluntary movement, but the limbs are not 
rigid, bending under slight force with the plasticity of wax. During the 
whole period there is complete anaesthesia. 

Hysterical sleep may last for a few hours or may endure for months, 
or even for years, provided the patient be regularly fed with liquid food. 
In some cases the patient awakes at regular intervals to take food. Con- 
sidering the small amount of food taken, the bodily nutrition is sometimes 
surprisingly maintained, but in prolonged cases there is great emaciation. 

Hysterical paralysis may simulate any form of organic palsy ; the face 
is not often affected, though hysterical facial paralysis and hysterical 
inequality of the pupil or strabismus do occur. In any form of hysterical 
paralysis the muscles may be relaxed or contracted, and the reflexes abol- 
ished or increased. Thus, in hysterical paraplegia there may be normal, 
abolished, or exaggerated knee-jerk, and there may be ankle- clonus. In 
hysterical hemiplegia the paralysis is rarely complete, rarely affects the 
face, and usually is distinctly more severe in one extremity. Hysterical 
monoplegias are common. 

Hysterical paralysis is very frequently accompanied with disturbances 
of sensation, such as hyperesthesia, — more commonly anaesthesia. Hys- 
terical disturbances of sensation may exist without motor paralysis. 

The hysterical anaesthesia may take the form of a hemianaesthesia, but, 



FUNCTIONAL NERVOUS DISEASES. 



409 



like hysterical hyperesthesia, is frequently irregular in its distribution. 
Large local areas, especially affecting the ovarian region of hyperesthesia 
or anaesthesia, are characteristic of hysteria. Hyperesthesia of the geni- 
tals is very frequent in the female, in whom it is usually associated with 
vaginismus and loss of sexual desire. A very common form of hysteri- 
cal hyperesthesia, which occurs especially in neurasthenic women, is the 
peculiar superficial tenderness over the vertebral column which is fre- 
quently, without reason, considered as a distinct disease, under the name 
of spinal irritation or spinal ancemia. In many of these cases the general 
hysterical symptoms are not pronounced. 

The disturbances of sensation often affect the different forms of gen- 
eral sensibility. Therrno-anesthesia is common, whilst wide-spread anal- 
gesia existing by itself is almost always of hysterical origin. This is also 
true of loss of electro-sensibility. The disturbances of sensation may be 
limited to a single organ, as the cornea of the eye, and may involve 
mucous membranes as well as skin and deeper tissues. Hysterical anes- 
thesia is usually accompanied by the so-called ischemia. In this con- 
dition the surface is pale and the needle-prick or even superficial incised 
wounds do not bleed. In anesthetic ischemia is found the explanation 
of the alleged miracle that in the Convulsionnaires of the Middle Ages 
superficial wounds were not followed by loss of blood. 

The special senses are frequently affected in hysteria. Sometimes there 
is a mere hyperesthesia, so that the normal function is performed with 
pain. Thus, photophobia is both frequent and severe. A true functional 
exaltation, especially of hearing, does, however, occur. In hysterical 
hemianesthesia the special senses are usually involved. Hysterical am- 
blyopia is frequently accompanied by a concentric narrowing of the field 
of vision, and sometimes by a loss of color-sense, achromatopsia, There 
may be simply contraction of the color-field, or contraction of both form- 
and color-field, or partial or complete reversal of the normal color- 
sequence, and the contraction of the field for form or for color may be 
greater in one eye than in the other. According to the researches of 
S. Weir Mitchell and de Schweinitz, in America achromatopsia is rare 
even when there is distinct contraction of the visual field, and, when it 
does occur, usually takes the form of reversal of the normal sequence of 
the colors, so that red is the largest field. 

A peculiar psychic involvement of the special senses is sometimes 
present. The thing put before the hysteric is seen or felt, but suggests no 
corresponding psychical idea, and hence is not recognized. This condi- 
tion occurs along with hysterical sensory and even ataxic aphasia. 

Hysteria frequently invades those functions of the body which are not 
directly connected with voluntary life. Cardiac irritability is very fre- 
quent and often very annoying ; in some cases a violent pain in the cardiac 
region, shooting down the arm, accompanied by excessive rapidity and 
smallness of the pulse, closely simulates angina pectoris. Disturbances 



410 



DISEASES OF THE NERVOUS SYSTEM. 



of the vasomotor system, are very common : of this nature must be con- 
sidered the sudden u flushings," which may be wide-spread, unilateral, or 
local ; also the peculiar local cedeniatous swellings which are often accom- 
panied with so much cyanosis that there are great blueness and coldness 
of the surface (blue oedema), as well as the swellings and enlargements 
about joints which may closely mimic organic disease. 

Possibly as the result of vaso-motor relaxation, hemorrhages occur 
from the nose or the stomach, and are especially prone to be severe when 
there is suppression of the menstruation. Care is sometimes necessary to 
avoid mistaking for a true hsemoptysis the bleeding produced by suck- 
ing or otherwise irritating the gums. At times even the trophic nerves 
appear to be affected : at least, cases of hysterical skin-irritation and hys- 
terical gangrene and hysterical erythromelalgia have been reported. 

The temperature rarely departs from the norm in hysteria, but ac- 
cording to the French writers there are three types of hysterical fever • 
in the first form the paroxysms are irregular, of long duration, and accom- 
panied by various nervous disturbances ; in the second variety the fever 
continues from one to four weeks, and is accompanied by disturbance of 
the nutrition, in some cases the whole course of the affection closely mim- 
icking that of a typhoid fever ; in the third form the paroxysms of fever 
recur with regularity, so as to give the appearance of a true intermittent 
fever. Eummo, according to Gilles de la Tourette, has found a decrease 
of urea-production in hysterical fever. Exaggerated temperatures, 120° 
or 130° F., have been recorded from time to time as occurring in hysteri- 
cal patients. Most, if not all, of these high records have been due to 
skilful manipulation of the thermometer by a designing patient, but there 
is reason for suspecting that extraordinary local elevations of temperature 
happen in hysteria. 

Eespiratory disturbances are common ; violent paroxysms of acute 
dyspnoea from hysterical laryngeal spasm may simulate true laryngismus 
stridulus. Hysterical aphonia from laryngeal palsy, and a hoarse, croak- 
ing, laryngeal cough, are very common. Intensely rapid breathing, from 
fifty to one hundred and fifty per minute, without alteration of the pulse- 
rate, with or without dyspnoea, occasionally occurs. 

Secretion is often affected ; profuse sweating, general or local, may 
occur, and may be attended with sufficient hemorrhage to color the 
perspiration deep rose-red (hwmatidrosis, Moody sweat). One of the most 
characteristic symptoms of the hysterical paroxysm is its passing off 
with an enormous discharge of limpid, almost colorless, urine of low 
specific gravity. More serious is the partial or even complete suppression 
of urine (anuria), which may for a long time so prevent the secretion of 
urea that the sweat and other secretions become loaded with it. 

Disturbances of digestion are almost universal ; excessive flatulence 
and constipation, enormous tympanitic distention of the bowels, oesopha- 
geal spasm interfering with swallowing, vomiting, which may be excessive 



FUNCTIONAL NERVOUS DISEASES. 



411 



and continue for days and weeks, are ordinary phenomena. In the 
severest cases of vomiting, fsecal matter, or even rectal injections, may 
be discharged from the mouth. The " fasting girls 7 ' of popular litera- 
ture are hysterics, who are able to live upon the smallest quantity of 
food and shrewd enough to deceive watchers. 

Diagnosis. — The recognition of the pronounced hysterical paroxysms 
is so easy as to require no discussion, but in the more larvated forms of 
hysteria the diagnosis may be made with great difficulty. In all cases 
of doubt great stress is to be laid upon the presence of an hysterical his- 
tory or of present symptoms of hysteria. Nevertheless, hysteria may 
coexist with organic nervous disease, as with organic disease of any char- 
acter, — a combination which sometimes leads to the gravest of errors. 
We have seen the diagnosis of nervous hysteria persisted in by good 
medical practitioners to within a few hours of the death of the patient, 
when an examination of the urine would have demonstrated the uremic 
nature of the attack. In all serious cases it should be an invariable rule 
to examine in the most thorough manner for the existence of an organic 
disease, and not to settle upon the conclusion that the symptoms are 
all hysterical because the patient has hysteria. On the other hand, 
hysterica] palsies of the most severe type may exist without other symp- 
toms of hysteria and without an hysterical history that can be made out. 
In recognizing the nature of such a palsy attention must be especially 
paid to the following points : the hysterical paralysis is apt to be transient 
and shifting, to go and come suddenly, and not to conform in its minor 
phenomena with the sequences and coincidences of organic palsy ; also 
to be accompanied by symptoms which do not occur in the organic 
paralysis which is simulated. Thus, an hysterical hemiplegia may be 
attended with paralysis of the bladder, or an hysterical - hemianesthesia 
accompanying the hemiplegia is not properly situated in its anatomical 
relations with the coexisting motor palsy, or electro-sensibility is lost 
when general sensibility is preserved, etc. An atypical paralysis in 
women is in the majority of cases hysterical ; in men it is, perhaps, 
somewhat more frequently syphilitic. 

An hysterical paralysis may immediately follow a slight injury. If 
contractures develop at once, or if after a time, in spite of complete 
paralysis and relaxation, there is no wasting of the muscles, or if there 
is any irregularity of position between the disturbances of sensibility and 
the alterations of mobility, or if there is even a very pronounced local 
anesthesia, the paralysis is probably hysterical. In coexisting organic 
palsy of sensation or motion, sensation almost always improves first ; in 
mimicking hysterical states, motion usually improves before sensation. 

In hysteria consciousness may be completely lost, but partial loss is 
more common and characteristic. In some cases the patient seems to be 
conscious during the attack, and afterwards has no remembrance of what 
has occurred j in other cases the patient appears to be unconscious during 



412 



DISEASES OF THE NERVOUS SYSTEM. 



the attack, but has a complete after- memory of what has happened. Both 
these conditions of subconsciousness are almost diagnostic of hysteria. 

In an hysterical affection of the joint simulating inflammation the true 
nature of the attack can usually be recognized by attention to the fol- 
lowing considerations : first, the muscular rigidity can be overcome by 
mildly persistent efforts while the patient's mind is diverted, and yields 
readily during sleep and disappears during anaesthesia or even under a 
full dose of chloral or opium ; second, there is no rise of temperature in 
the joint, although the parts look red and inflamed ; third, in muscles 
which have apparently undergone atrophy the electrical reaction remains 
normal ; fourth, the loss of function of the part varies greatly from time to 
time as the patient's attention is diverted from it, and is also exaggerated 
by fatigue and nervous exhaustion. In the onset of an organic disease 
of the joint interference with function is prone to precede the develop- 
ment of pain ; in the hysterical disorder pain generally appears first. 

Hysterical lateral spinal curvature occurs in neurasthenic women, in 
whom a true lateral curvature is very frequent ; unlike true lateral cur- 
vature, it is usually an outcome of spasm and disappears during sleep or 
anaesthesia. 

A localized swelling in the abdomen of hysterical women sometimes 
gives upon palpation the feeling of a hard tumor {phantom tumor) ; ordi- 
narily the presence of percussion clearness renders the diagnosis easy, 
but even in moderately obese women this sign sometimes fails. During 
anaesthesia the phantom tumor, being the outcome of muscular spasm, 
disappears. 

The nature of the hysterical breast is to be recognized by the excessive 
superficial tenderness, so that slight irritation produces as much distress 
as hard pressure, by the diffuseness of the swelling and the constant 
variation in the size and hardness of the breast, and by the increase 
of symptoms at the menstrual period, at the approach of stormy weather, 
or after general fatigue. In many instances the coming and going of the 
symptoms make the nature of the case unmistakable. In girls, and not 
rarely in neurotic boys, at the period of sexual unfolding, one breast will 
suddenly become hot and exceedingly painful and tender, and perhaps 
there will be escape of a few drops of sero -lacteal fluid, the whole being 
a neurotic phenomenon and subsiding without injury. 

Prognosis. — In our opinion, it is doubtful whether death ever occurs 
from hysteria : the reported cases have probably been instances of con- 
fusional insanity, acute mania, or other disease. The prospect of cure 
in a case of hysteria is in inverse proportion to the age at which the 
hysterical temperament has appeared. An acquired hysteria, due to 
some removable or temporary depressing cause, may rapidly yield to 
treatment, but a congenital hysterical temperament can only be abated. 

Treatment. — By proper education from early childhood it is possible 
largely to modify the nervous temperament and often to prevent the 



FUNCTIONAL NERVOUS DISEASES. 



413 



development of hysteria. The indications are — first, to increase the 
robustness of the whole person, and especially of the nervous system ; 
second, to reduce excessive sensitiveness by accustoming the nervous sys- 
tem to moderate exposure and hardships ; third, to develop in the child 
the habit of obedience (first to those who are above it, and afterwards to 
its own personality, led by a sense of right and wrong ; in other words, 
to teach the habit of subjection to control from without, in order that the 
power of self-control from within may later be developed) ; fourth, to 
bring about as much of intellectual development as shall give to the 
child abundance of interest outside of itself and its immediate surround- 
ings and shall form a basis for character ; fifth, to inculcate unselfishness 
and to develop other traits of character such as are recognized as worthy 
of imitation throughout the world. When, where, and how these things 
shall be done must depend upon the circumstances of the individual child. 
Country life is usually preferable to city life ; a moderate living, to a home 
of luxury ; home training, to training in boarding-schools or other insti- 
tutions ; plain food, to high living. In all cases it is essential that those 
who have charge of the child be themselves not nervous or hysterical. 

In developed hysteria the basal treatment must ordinarily be that of 
neurasthenia. The rigidity with which this treatment must be enforced 
depends upon the needs of the individual case. Living in the open air, 
with plain and simple but nutritious food, graded exercise, and freedom 
from care, social dissipation, or other excitements, in some cases will suf- 
fice ; but in severe cases the removal from home, the putting to bed, the 
isolation of the so-called " rest-cure," are not only of the greatest physical 
benefit, but afford opportunity for that domination and moral training by 
the physician and the nurse which are so essential to the welfare of the 
hysteric. Under these circumstances the selection of the nurse is a matter 
of the greatest importance. She must have the tact to control the patient 
without causing unnecessary irritation, and must in her person be, as far 
as may be, agreeable to the patient. The intent of the moral management 
of the hysteric is to develop, first, a willingness to be unselfish, and, 
secondly, the habit of self-control. In exceptional cases a careful, skilful 
unrolling of her own character, of its difficulties, its dangers, and its pos- 
sibilities, has a most happy effect upon the intelligent victim of hysteria. 
Usually, however, it is necessary first to teach the habit of obedience or 
submission to control from without, which habit, when acquired, becomes 
the basis of advance of character to self control. 

The patient must first be made to perceive that complaints do not 
bring sympathy, but cause disgust and disregard. The hysterical attack 
must be made as disagreeable as possible ; this not simply to prevent the 
wilful bringing on of the attacks, but to afford a motive which shall aid 
the will of the patient in preventing an attack. The paroxysm may 
usually be cut short by the hypodermic injection of apomorphine, by the 
cold bath, and by other procedures. In hospital practice the severest 



414 



DISEASES OF THE NERVOUS SYSTEM. 



paroxysms are sometimes set aside by threatening to cut the hair, by 
opening soda-water siphons in the face, and by other rough measures, 
which, although they may be justifiable against professional hysterics 
who are using the paroxysms for definite purposes, in the continuous 
treatment of the disorder do harm rather than good. Sometimes, how- 
ever, measures of such character are of the greatest service if used with 
due caution and judgment. Some time since, a furious epidemic of hys- 
teria occurred in a Philadelphia charitable institution for the care of 
children, and required the temporary scattering of the children among 
various hospitals. In two of the cases no treatment interrupted the re- 
turn of the paroxysms until the children were kept without food for three- 
quarters of a day and then heavily fed, after which to one of them in the 
presence of the other was given ether as slowly and as disagreeably as 
possible, so as to provoke screaming, fighting, and excessive vomiting, 
the result being the immediate cure of both cases. 

It is often of the greatest importance to afford a strong motive which 
shall reinforce the weak will of the hysterical person. As is well known, 
emotional excitement will temporarily, or perhaps permanently, put an 
end to long- continued hysterical palsies j but the creation of an emotional 
excitement is entirely different from the installation of a powerful per- 
manent motive. 

Even of more influence than a strong motive are faith on the part of 
the patient and powerful dominant ideas. It is probable that in this way 
act hypnotism, mock surgical operations, bread-pills given with abso- 
lute carefulness as to detail of administration, faith-cures, pilgrimages, 
metallic tractors, magnetism, and the numerous procedures which, having 
little or no direct remedial powers in themselves, have yet cured numerous 
cases of hysteria. Hypnotism is sometimes of the greatest value, but it 
is necessary, in employing it, to exercise great care, lest the attention 
which it brings to the patient, and even the state itself, may do injury. 
In accidental or acquired hysteria hypnotism may be used more freely 
than in the original neuropathic disorder. It is not, according to our 
belief and experience, any suggestions made in the hypnotic state that 
do good ; we have cured hysterical contractures, tremors, paralysis, etc., 
by hypnotism without any suggestions, the result having been, no doubt, 
due to a mental impression. 

In bad cases of hysteria it is very important that the physician do 
not intensify the symptoms by too much attention. The hysterical woman 
craves sympathy inordinately, and occasionally has towards the doctor 
distinctly sexual feelings. In hysterical retention of urine the nurse, not 
the doctor, should draw off the urine. In hysterical vomiting no atten- 
tion should be paid to the symptom unless it becomes so severe as to 
threaten the general nutrition, when the various anti-emetics, especially 
cocaine, and blisters upon the epigastrium, may be tried. Artificial 
feeding should soon be resorted to ; semi-liquid, half- digested food should 



FUNCTIONAL NERVOUS DISEASES. 



415 



be given by means of the nasal oesophageal tube, and, if it be not 
retained, by the rectum. 

In hysterical special-sense hyperesthesia it is essential that the patient 
should not be shut up in a dark room or an extremely quiet apartment, 
but that she should be forced to endure at least a moderate portion of the 
normal stimulus which is affirmed to cause pain. Blisters behind the 
eyes, closure of one or both eyes with sticking-plaster, etc., may some- 
times be resorted to with good effect, but are liable if used injudiciously 
to do harm by riveting the attention of the patient upon the symptom. 

Tonics and antispasmodics are sometimes useful in the treatment of 
hysteria. Asafetida, valerian, musk, and even camphor, may be em- 
ployed freely, as there is scarcely any danger of doing injury with them. 
The bromides have more power than any of these remedies, but are dis- 
tinctly more capable of harm ; whilst chloral, morphine, and other nar- 
cotics, though sometimes it may be necessary to use them, are dangerous. 
There is always overhanging the use of these narcotics, and especially 
the use of alcohol, the gravest danger of the narcotic habit. It must not 
be forgotten that the pains of the hysteric which are complained of as 
unutterable agony often disappear in a moment under pleasurable ex- 
citement. Cannabis indica is especially useful when the headache takes 
on the character of migraine. 

In hysterical pseudo-angina it is probable that the pain is due to some 
disorder of the cardiac apparatus, and is not itself, therefore, directly 
hysterical. Certain it is that the pain may often be relieved by nitro- 
glycerin or amyl nitrite, and the paroxysm set aside by the persistent use 
of cardiac tonics, such as digitalis and caffeine. 

In spinal irritation and in hypersesthetic ovaries, mild counter-irrita- 
tion is sometimes of service, though a better result is often obtained by 
the application of a belladonna plaster. Hypodermic injections of water 
are frequently most efficacious in relieving severe pains or overcoming 
insomnia, provided the hysteric believes that the water is a strong solu- 
tion of morphine. 

ASTASIA ABASIA. 

Definition. — A condition in which the patient when lying down can 
move both legs and arms without disturbance of power of coordination, 
but cannot stand up or walk. 

Symptomatology. — This condition, which appears to have first been 
described by Blocq in 1888, may develop suddenly or may come on 
gradually. It may exist in its complete form or in any degree of par- 
tialness. Eelapses are said to be common after coitus. Three forms 
of it can be made out : the distinctly hysterical (hysterical ataxia, Weir 
Mitchell), in which at first the patient is often unconscious of the exist- 
ence of the condition 5 the hypochondriacal ; and the psychical, in which 
it is dependent upon a dominant idea. In the hypochondriacal form 
the attempts to walk or stand are usually associated with great anxiety 



416 



DISEASES OF THE NERVOUS SYSTEM. 



and mental distress, violent palpitation, giddiness, various paresthesia, 
and disturbances of vision. The most plausible explanation of astasia 
abasia is that it is the result of loss of power of the cortical centres 
which coordinate the actions of standing or walking, although the exist- 
ence of such centres has never been demonstrated. 

Treatment. — The underlying neurasthenic or hysterical condition 
must be rectified. Friedlander advises also careful systematic gymnastic 
training : first, passive movements lying down ; second, resistant move- 
ments lying down ; third, resistant movements in sitting posture ; fourth, 
resistant movements in standing posture ; fifth, standing without sup- 
port ; sixth, practice in starting ; seventh, practice in walking. 

SINGULTUS. 

The peculiar convulsive motion of the diaphragm and neighboring 
parts, known as Hiccough or Hiccup, may be of reflex origin, due to 
disease of the lungs, peritoneum, stomach, liver and gall-bladder, intes- 
tines, uterus, or prostate, or to mediastinal tumors. It also may be the 
outcome of disease at the base of the brain, or may be purely functional. 
In alcoholism, rachitis, or typhoid and other low fevers, etc., it may be 
the cause of death. 

Treatment. — Very cold or very hot or irritant drinks sometimes 
are of service. Cocaine, musk, the bromides, camphor, chloroform, 
given by the mouth in full dose, are often efficient. Chloral, amyl 
nitrite, hypodermic injections of morphine with atropine, and even in- 
halations of ether, may be used on occasion. In very persistent cases 
threatening life, the stomach may, if circumstances favor, be washed out 
and then allowed to rest absolutely from food, drink, or medicine for 
one, two, or even three days. The patient during this time should re- 
ceive digested nutritive enemas and an enema of feebly alkalized water 
(sodium carbonate), as large as can be retained, alternately every four 
hours, sufficient chloral and opium being put in these enemata to main- 
tain a semi- narcotism, or at least to control the hiccough. Stimulants 
may, if required, also be given by the rectum. 

VERTIGO. 

Definition. — A sensation of motion or swimming in the head, or an 
appearance of motion in surrounding objects which really are at rest.* 

As vertigo is really a symptom, it may arise from very many causes. 
The peculiarities of a vertigo have no known relations with its causes. 
For the purposes of diagnosis and subsequent treatment it is essential to 



* Strictly speaking, vertigo is the whirling of objects around the person ; giddi- 
ness, the sensation of swimming in the head or motion in the head. But, as the two 
conditions vary indefinitely in their manifestations and grade in every possible way 
into one another, the term vertigo has come to be employed as including all disorders 
of cerebral sensation affecting co5rdination. 



FUNCTIONAL NERVOUS DISEASES. 



417 



recognize the cause of the symptoms. The most important etiological 
varieties of vertigo are enumerated as follows : 

Organic vertigo may be produced by any form of brain- disease, as well 
as by locomotor ataxia, probably from involvement of the portion of the 
base of the brain. 

Epileptic vertigo. See Epilepsy. 

Cardiac vertigo is usually the result of cardiac fatty degeneration or 
other form of failing heart ; it is really syncopal. Mai de montagne (the 
headache, vertigo, dyspnoea, nausea, and vomiting produced in some 
persons by high mountain ascent), and the swimming of the head seen 
in individuals with arterio sclerosis, are probably also due to lack of 
blood-supply to the brain. 

Hysterical vertigo usually, but not always, takes some bizarre form. 

Peripheral vertigoes are produced by irritation in parts of the body dis- 
tant from the brain. The most important of them is the so-called gastric 
vertigo, which in its acute form is often associated with intense headache 
and partial blindness or double vision, and is usually relieved by vomiting. 
It is often directly traceable to the use of strawberries, lobsters, shell-fish, 
or other articles of diet out of harmony with the digestion of the indi- 
vidual. Chronic gastric vertigo, due to persistent dyspepsia, in which 
the vertigo recurs frequently from two to four hours before eating, is a 
much rarer affection even in dyspeptics than is the gastric vertigo directly 
due to irritation of the stomach. How far chronic dyspeptic vertigo is 
the outcome of gastric irritation, and how far it is due to the presence in 
the blood of poisons from imperfect digestion, is uncertain. A peculiar 
giddiness, with a sense of weight or intense pain in the eyes, may be the 
only manifest symptom of tape-worm. Polypi and other gross laryngeal 
lesions have in some cases produced distinct vertigo. Irritation of the 
nasal mucous membrane, and of the gums by retained teeth, may also be 
enumerated among the causes of peripheral vertigo. 

Special- sense vertigo is in one of its forms the condition which is pro- 
duced by whirling movements, by swimming, by the rocking motion of 
the ocean, and is probably due to disturbance of the circulation, especially 
in those portions of the special-sense apparatus which are connected with 
equilibration or are in some way irregular. Distorted sense perceptions 
have, however, in themselves the power of producing giddiness. Thus, 
nystagmus, paralysis of the external rectus, and more rarely of other eye- 
muscles, may produce a vertigo which is probably the result of the con- 
fusion caused in the nerve-centres by the non-agreement of the perceptive 
organs in their registration of objects. Usually, closure of one eye puts 
an end to ocular vertigo. In some cases, however, it fails to do so, prob- 
ably because there is still a confusion between the reports to the brain of 
vision and of the senses of touch and hearing. An acute paralytic squint 
is almost always accompanied by double vision and giddiness. The con- 
comitant squint — i.e., the squint due to diseases of the eye itself— is 

27 



418 



DISEASES OF THE NERVOUS SYSTEM. 



rarely accompanied by either of these symptoms, probably because it is 
usually very slowly developed and the brain- centres form the habit of 
disregarding the visual images in one of the two eyes. Disturbances 
even of the external ear or of the Eustachian tube may produce vertigo 
which is probably reflex. Diseases of the aural labyrinth are very prone 
to cause pronounced vertigo, and sudden congestion or apoplexy of the 
semicircular canals may give rise to a sudden, violent vertigo, accom- 
panied by excessive pallor, sweating, and symptoms of imminent syn- 
cope, or even death. Such cases were first described by Meniere in 
1861, and constitute Meniere's disease, which must be distinguished from 
VoltolinVs disease , which is an acute purulent labyrinthic otitis, accom- 
panied by violent pain, and followed by complete unconsciousness, high 
fever, and delirium. Chronic labyrinthine disease may cause a persistent 
aural vertigo, which, however, should not be called Meniere's disease. 

Toxemic vertigo may be produced by alcohol or various poisons or by 
ura3mia, or may be the result of lithseinia ; indeed, a lithcemie vertigo is 
the most common form of vertigo, and often causes the greatest alarm. 
Its true nature is to be recognized by detecting the lithseinia. 

Essential vertigo represents a class of infrequent cases in which the 
vertigo may be very severe and yet no cause be discoverable. It is 
probable that in these cases there are lesions of still unrecognized brain- 
centres of equilibration. 

Treatment. — There is no known specific treatment of vertigo. Be- 
lief is to be obtained by learning the cause of the vertigo. When this 
cannot be reached nothing can be accomplished. 

EPILEPSY. IDIOPATHIC EPILEPSY. 

Definition. — A disease of unknown pathology, in which at irregular 
intervals and without obvious existing causes nerve disturbances occur, 
in most cases accompanied by loss of consciousness and very frequently 
by convulsive movements. 

Etiology. — Epilepsy is probably in about twenty-five per cent, of 
the cases due to direct inheritance. In a large number of cases it is the 
exaggeration of the neuropathic root-stock. Alcoholism, consanguineous 
marriages, scrofula, rachitis, extreme poverty or dissipation, anything 
which exhausts the vitality of the parent and tends to the production of 
nerve-degeneration in the child, has a great influence in the production 
of the congenital epileptic diathesis. This diathesis is probably also the 
outcome of transitory unnoted conditions in either parent at the time of 
conception, or in the mother during pregnancy. Epileptiform attacks 
produced by chronic poisonings (especially chronic alcoholism), by 
peripheral irritation, by violent emotional disturbances, if repeated, may 
cause a continuing epilepsy by forming in the nervous system the habit of 
discharging paroxysmally nerve-force at irregular intervals. Epilepsy is 
somewhat more frequent in the male than in the female, and may develop 



FUNCTIONAL NERVOUS DISEASES. 



419 



in very early infancy. In a large proportion of cases it appears abont the 
time of puberty. Probably about one-fourth of the cases have the first 
convulsion under thirteen years of age, one-half under nineteen years, 
and the remaining one-fourth under thirty years. The number of cases 
occurring beyond the age of thirty years is so small as not to affect 
statistics. 

Morbid Anatomy. — Although after death the brain of the epilep- 
tic is often found diseased, and although various assertions have been 
made as to the nature of the lesion of epilepsy, no clear light has been 
thrown upon the subject, unless it be by the researches of Ghaslin, who 
asserts that the basal lesion of epilepsy is a non- inflammatory degenera- 
tion, in which the neuroglia of the brain is transformed into an abnormal 
tissue composed of bundles of fibrillae much longer and much more dis- 
tinct than those in normal brains. The nerve- cells are reduced in size 
and number, and their processes shrunken or altogether removed ; the 
capillaries are for the most part completely intact, without that cellular 
infiltration of their walls, and especially of their sheaths, which is so 
pronounced in inflammatory sclerosis. Some of the capillaries, however, 
are dilated, and occasionally there is one with its walls thickened. There 
is no reason for believing that there is any special connection between 
the disorder and disease of the cornu Ammonis, although Sommer, Hoff- 
mann, and Fischer have reported cases in which there was demonstrable 
disease of that convolution. It is much more probable that the lesion, 
whatever it may be, especially affects the psycho-motor zone. 

Of the numerous theories of the disease which have been brought 
forward, only two are worthy of notice here. These are — first, the vaso- 
motor theory, that the convulsion is due to the sudden overaction of the 
vaso-motor centre in the medulla, contracting the brain-vessels and 
causing a convulsion by anaemia ; second, the discharge theory, in ac- 
cordance with which the cortical cells become at irregular intervals so 
surcharged with nerve-force that an overflow occurs and produces a gen- 
eral disturbance. Of these theories the latter is the more plausible. 
It should be noted, however, that it does not elucidate the ultimate nature 
of epilepsy, but simply explains the mechanism of the paroxysm. 

Symptomatology.— The typical epileptiform convulsion begins with 
a peculiar sensation, which is known as the aura, and is succeeded at once 
by a wild, harsh scream, the epileptic cry, and also by complete un- 
consciousness, accompanied by a general tonic spasm. This period of 
tonic spasm is accompanied by pronounced pallor of the face, and lasts 
from a few seconds to two minutes. In it the head and eyes are usually 
turned violently to one side, and the facial muscles contracted, — in most 
cases most markedly on the side towards which the head is turned. The 
jaws are fixed, the arms flexed at the elbows and still more strongly at the 
wrists, whilst the fingers and thumbs are bent into the position assumed 
in grasping a pen, on account of the conjoint spasm of the interosseous 



420 



DISEASES OE THE NERVOUS SYSTEM. 



and flexor muscles. The position of the extremities is that of universal 
tonic spasm, the parts being drawn in the direction of the muscles of 
superior power, so that there is violent extension of the limbs, with 
inversion and extension of the feet, clenching of the hands, and some 
opisthotonos. After a time vibratory tremors commence, and gradually 
grow more and more severe, until they are lost in furious clonic spasm 
in which the limbs are alternately relaxed and jerked in movements as 
wild and bizarre as they are uncontrollable. Purposive movements 
never occur. During the period of clonic spasm the face becomes 
red, congested, bloated, livid, with a continual change of expression as 
the spasm involves now this and now that muscle of the face. Owing 
to the violent working of the muscles of mastication, the saliva is forced 
from the mouth in the form of bloody froth. Even in the tonic spasm 
the tongue may be bitten, but during the clonic spasm it is continually 
thrust in and out of the mouth and is almost sure to be badly cut. The 
pupils at the beginning of the fit may be contracted, but absolutely 
immovable dilatation occurs very early and is the characteristic condi- 
tion, interrupted sometimes by extraordinary oscillations. The return 
of the pupils to the normal state may be one of the earliest evidences 
that the paroxysm has passed. During the height of the attack all 
reflexes are abolished. The sphincters may be relaxed. 

According to Magnan, in the early tonic stage of an epileptic attack 
the pulse may be very slow, but during the height of a paroxysm it cer- 
tainly is increased in frequency and in force. The respirations are ster- 
torous, slow, and irregular. In severe fits the pauses between them are 
sometimes so long that the patient appears to have stopped breathing. 
If death occurs in the fit, it is from such arrest of respiration. The 
bodily temperature usually rises, — rarely, however, above 102° F. 

The stage of clonic convulsion seldom lasts over three minutes, and 
is followed by coma, and then by deep sleep, which may continue three 
or four hours. The patient, after awakening, suffers from headache, 
malaise, and general muscular soreness. Directly after the paroxysm 
the knee-jerk is very often wanting, but the reflex activity is regained 
in from one to thirty minutes, and may become excessive. 

The description just given is that of a typical epileptic major convul- 
sion 5 but any of the phenomena may be wanting. Before discussing 
further these anomalous epilepsies, it seems advisable to say a few words 
in regard to some of the individual symptoms. 

The epileptic cry is frequently absent, and if it occur more than once, 
or more than twice at the most, the suspicion of hysteria should be 
aroused. The aura, which is often absent, takes a great number of forms. 
Probably the most common is the gastric aura, a sense of distress, or 
weakness, or trembling, or of some paresthesia, starting in the stomach 
and ascending. The initial point of the aura may be a finger, the hand, 
the foot, the face, the tongue, the larynx, the pharynx, or any other 



FUNCTIONAL NERVOUS DISEASES. 



421 



part of the body. In either ease, when the ascending wave reaches the 
neck, unconsciousness usually develops at once. The aura may originate 
in the brain or in one of the special senses. The psychical aura may 
consist of an emotion or of an idea. Usually the emotion is one of 
terror, and the idea something disagreeable. 

Of the special sense auras the ocular is the most frequent, the gusta- 
tory the rarest. The ocular aura may consist of colors, of megalopsia, 
of micropsia, of double vision, of amblyopia deepening into complete 
blindness. In the auditory aura various sounds and even words may be 
heard. Any of these auras may be accompanied by a distinct hallucina- 
tion, which usually takes the same form in successive fits. The aura 
commonly is instantaneous, but in rare cases it travels so slowly that one 
or even more minutes are required for the development of the fit. 

Anomalous Epilepsies. — The most important anomalous epilepsy is 
the so-called petit mal, which in its ordinary form consists of a momen- 
tary loss of consciousness, accompanied (not always) by excessive pallor 
of the face, usually followed by immediate resumption of intellectual 
action, sometimes by consciousness of thought. Between this petit 
mal and the gros mal, or major attack, every grade of paroxysm occurs. 
The petit mal may be accompanied by an aura, by the epileptic cry, 
by general quiet muscular relaxation, and varies in its length. The 
most characteristic and essential feature of the epileptic paroxysm is the 
loss of consciousness, and yet without doubt during an epileptic attack 
consciousness may be preserved. A slow aura may sometimes be arrested 
and the paroxysms be aborted by a tight compression of the limb above 
the initial point ; and we have seen cases in which the aura habitually 
suffered spontaneous arrest at a certain point with abortion of the other 
symptoms. 

In the early development of an epilepsy in a child the whole paroxysm 
may consist of a sudden painful sensation in the stomach, with pallor, 
but without loss of consciousness, these paroxysms continuing in spite 
of treatment, and slowly changing, after years it may be, into a fully- 
formed epilepsy. 

Hughlings Jackson has reported a case in which the attacks of petit 
mal consisted of a brief mental confusion with aphasia ; C. H. Vere one 
in which the chief phenomenon was a furious salivation. 

Nocturnal epilepsy is that form in which the attack occurs at night, 
either with or without the patient being awakened. 

Epilepsia procursiva, or procursive epilepsy, is that form in which, with 
or without a primary epileptic cry, the patient starts to run forward or 
in a circle and after a time wakes up or falls in a convulsion or coma. 
This procursive epilepsy is rarely preceded by an aura : it is sometimes 
due to organic diseases of the brain, but may represent idiopathic epi- 
lepsy, and may develop into the ordinary form, or continue for years 
unchanged. It is said to be closely associated with moral degradation. 



422 



DISEASES OF THE NERVOUS SYSTEM. 



Epileptic automatism is that condition in which, simple or complicated 
acts apparently involving consciousness are performed by the subject, 
who has at such time no proper control of himself or knowledge of his 
surroundings, and also has no after-memory of the occurrence. Epi- 
leptic automatism may represent the whole paroxysm, or may precede a 
convulsion, but in the majority of cases it follows a convulsion, which 
under such circumstances is rarely severe. In its mildest form the 
automatism consists in doing something out of the common, such as 
removing the clothing, secreting small objects, etc. In many cases the 
series of acts are so complicated and apparently rational that it is almost 
impossible to persuade by-standers that the subject is not conscious. 
Usually there is no emotional excitement in epileptic automatism ; some- 
times, however, the contrary is the case, when epileptic automatism passes 
into epileptic mania. This mania may take the form of acute mania or of 
an agitated melancholia. In either case the incoherence is usually less 
than in the corresponding non-epileptic affection. The attack is in most 
cases sudden, and often has for its first phenomenon a period of violent 
disconnected speech, which is followed by the mania, or by an ambitious 
or mystic or erotic delirium, in which sentence after sentence flows forth 
with extraordinary volubility. Sometimes there is a delirium of persecu- 
tion. Hallucinations are almost universal, and affect all the senses ; they 
and the delusions to which they give rise conform to the type of the emo- 
tional disturbance. The delirium may last from a few minutes to several 
days, and is characterized by a tendency to acts of extreme violence, 
destructive, suicidal, homicidal. Even when the mania is apparently of 
mild type there may be a sudden outbreak of the greatest fury, in which 
the patient runs amuck at all objects within reach, and, if possible, 
commits homicide. 

The course of epilepsy is essentially chronic, with in most cases a final 
disturbance of intellection which frequently ends in great mental degra- 
dation and even complete dementia. Sometimes a permanent insanity 
develops in the epileptic, usually in the form of a melancholic paranoia, 
with delusions of persecution and suicidal impulses. In these cases it is 
probable that both the epilepsy and the insanity are the offspring of an 
original neuropathic vice of constitution. The characteristic mental state 
of chronic epilepsy is a progressively lowered mental power, with a pecu- 
liar irritability and brutal selfishness, accompanied by outbreaks of furi- 
ous anger on the slightest provocation. Even while the mental powers 
are still active, epileptics are frequently peculiarly irritable and revenge- 
ful ; after a paroxysm these tendencies are increased. The epileptic status 
is a condition in which the patient remains for many hours unconscious, 
with constantly recurring paroxysms. The likeness of such an attack to 
apoplexy is increased by the rise of temperature, which may reach 110° F. 

The epilepsy which has just been described is the ordinary disorder 
occurring without apparent cause ; but epileptic attacks may be produced 



FUNCTIONAL NERVOUS DISEASES. 



423 



by various causes and simulate the so-called idiopathic or true epilepsy. 
Reflex epilepsies are those in which the convulsions are due to peripheral 
irritation. Toxcemic epilepsies are those in which the convulsions are due 
to poisons, notably to alcohol, to lead, to veratrine, etc. 

In cardiac epilepsy it is doubtful whether the nervous attacks should be 
considered primary or secondary. Two varieties of the affection exist. 
In one form the pulse becomes very slow, falling, perchance, to ten or 
even less per minute, with generally subnormal temperature, a face at 
first pale and then livid, and, it may be, stertorous breathing. The par- 
oxysm may be ushered in by a distinct aura-like sensation ; the convulsive 
movements are usually not severe. In the second form of cardiac epi- 
lepsy the heart's action is tremendously excited and powerful, the face 
deep purple, spotted or blotched with ecchymotic exudations, the con- 
junctiva greatly swollen, deep red in color, often ecchymosed or even 
freely bleeding. Epistaxis is apt to be severe, and may seemingly bring 
relief. The convulsion is usually violent. There is strong probability 
that both forms of cardiac epilepsy start from the heart or its innervation. 

Diagnosis. — The recognition of an epileptiform convulsion is so easy 
as to require no further discussion. The decision that the convulsion is a 
manifestation of idiopathic epilepsy requires that it should be shown that 
it is not due to organic epilepsy, or to reflex epilepsy, or to toxsemic epi- 
lepsy. The final decision that the case is not one of these disorders must 
in the end rest chiefly upon the failure to find disease of the nervous 
system, a peripheral irritation, or a possible toxic cause. 

If the convulsion begin habitually in one limb, one side of the face, 
or other limited muscular territory, and especially if it be confined to 
such part, the gravest suspicion should be aroused that the case is one 
of Jacksonian epilepsy, due to organic focal brain- disease. An epi- 
lepsy in which no change can be demonstrated in the nerve-centres may, 
however, take on the Jacksonian type, so that it is usually wise to wait 
for distinct symptoms of organic brain- disease which shall be permanent 
in character (a temporary partial aphasia or monoplegia may follow a 
paroxysm of idiopathic epilepsy) before reaching a positive conclusion. 

Eeflex epilepsy usually conforms in its type to the idiopathic disease ; 
its nature is to be made out only by discovering and noticing the effect 
of the removal of the point of irritation. The practitioner should there- 
fore thoroughly examine every epileptic for points of irritation. Wounds 
in the head and other portions of the body, astigmatism and other im- 
perfections of the eyes, diseases or malformations of the nasal cavity, 
carious teeth, and especially retained milk teeth, aural diseases, adherent 
prepuce, intestinal worms, have in numerous cases provoked reflex epi- 
Leptiform convulsions. 

Of the toxaeinic epilepsies the alcoholic may simulate not only the 
grand mal but also the petit mal. In our experience reflex epileptic con- 
vulsions rarely, if ever, occur in groups, but the alcoholic epilepsy sinm- 



424 



DISEASES OF THE NERVOUS SYSTEM. 



lates the idiopathic disease in the tendency to the occurrence of groups 
of paroxysms and of an epileptic status. Further, in some cases the 
attack of alcoholic epilepsy is followed by a mental derangement simu- 
lating epileptic automatism, but in most cases differing from it in that 
the alcoholic subject during the condition obeys immediately and mechan- 
ically all influences coming from without. The convulsions of ursemia 
and of saturnine encephalopathy may very closely resemble those of 
idiopathic epilepsy. 

The greatest aid in the diagnosis of a true epilepsy may be obtained 
from the consideration of the age at which it appears. If the first convul- 
sion occur after the age of thirty years has been reached, the diagnosis of 
idiopathic epilepsy must be made with great reluctance, and it may be 
considered as a fixed rule with the rarest of exceptions that an epilepsy 
(not hysterical) which develops after the thirty -fifth year of age is not 
idiopathic, but is due to organic brain-disease, to alcoholic or other tox- 
aemia, or to reflex irritation.* 

The greatest difficulty is sometimes experienced in distinguishing 
between hysteria and idiopathic epilepsy. It should be remembered that 
hysterical phenomena frequently follow a purely epileptic convulsion, 
and we have seen long series of hysterical convulsions which have re- 
sembled idiopathic epilepsy closely enough to warrant the diagnosis of 
the idiopathic disorder. Usually the nature of the case can be made 
out by noticing the following points. In hysteria the paroxysm is at- 
tended with great emotional disorder, purposive movements, and espe- 
cially tetanic rigidity ; the muscular contractions also are irregular and 
produce lasting bizarre movements. The epileptic paroxysm has no 
emotional disturbance until after the fit ; the muscular contractions, 
except in the Jacksonian type, involve the whole body, and there is no 
apparent purpose in them. 

Aid to diagnosis can often be obtained by a study of the temperature. 
In ursemic convulsions the temperature is often subnormal ; it may, how- 
ever, rise. In the single isolated epileptic attack the temperature usually 
rises distinctly, and in the epileptic status is often very high. The single 
hystero-epileptic attack is accompanied by only a slight rise of tempera- 
ture, and when there is a series of convulsions the temperature falls 
immediately after each convulsion, and does not after successive attacks 
reach distinctly higher than with the first convulsion. 

Prognosis. — In epilepsy the prognosis .so far as the individual fit is 
concerned is highly favorable, death occurring in the fit with extreme 
rarity. So far as the disease itself is concerned, the prognosis is highly 
unfavorable, it being very doubtful whether complete recovery ever occurs 
from true idiopathic epilepsy. We have seen the fits recur, under con- 



* In an experience including over a thousand cases of epilepsy I have not met 
with more than one or two, and those doubtful, exceptions to the rule. (H. C. TY) 



FUNCTIONAL NERVOUS DISEASES. 



425 



tinuous treatment, after having been absent for six years. The disease 
does not necessarily or even usually greatly shorten life, the epileptic 
very often living to advanced middle life or even to old age. The ques- 
tion as to the intellectual future of an epileptic is always of most serious 
import. The resistance of the brains of different individuals to retro- 
grade epileptic changes varies very greatly, but three rules may assist the 
practitioner in his prognosis : first, the earlier the age at which the epi- 
lepsy commences, the greater the probabilities of serious mental deterio- 
ration ; second, very rarely, if ever, is there any distinct recovery of 
power, so that symptoms once established are usually permanent ; third, 
the more frequent and severe the fits, the greater the chances of intel- 
lectual ruin. 

Epilepsy does not, however, necessarily end in mental degradation, 
even when it has come on early ; when it has existed some years with- 
out producing any serious intellectual results the chances are always in 
favor of the escape of the patient from deterioration. Many epileptic 
persons pursue with activity and success a business or even a professional 
life. In estimating the prospects of a case it is essential not to mistake 
emotional excitement, pseudo- convulsions, or even pseudo-mania, for 
symptoms really of epileptic origin and evidences of permanent intellec- 
tual change. Such symptoms may be hysterical, and under treatment 
may disappear ; whereas the true epileptic mental failure is without 
doubt the result of change in the brain-structure, and is hopeless of 
relief. 

In estimating in any individual case the chances of amelioration, the 
question whether the patient has or has not been skilfully treated enters 
very largely into the judgment. Again, a petit mal usually yields less to 
remedies than does a severe epilepsy. The more frequent and severe 
the attacks are, provided the patient has not been already under proper 
treatment, the more brilliant are the results to be hoped for. 

Treatment. — The treatment of idiopathic epilepsy naturally divides 
itself into that of the individual paroxysm and that of the series. As the 
epileptic fit very rarely does immediate harm, all that is usually necessary 
is to place the patient so that he cannot injure himself ; to loosen at once 
all tight bands, especially about the neck, and, in order to prevent cutting 
of the tongue, to push between the teeth a piece of flat cork or rubber 
with a string tied to it, so that if by any means it should get into the 
throat it may readily be withdrawn. The inhalation of ether will usu- 
ally put an end to the convulsion, and in our observation has never done 
harm. While, therefore, it is not necessary, it may be useful to quiet 
the alarm and satisfy the craving for action of nervous mothers and other 
care-takers. Eesistance aggravates the convulsive movements, and should 
not be employed unless the patient be in position of peril. After the 
attack the subject should be allowed to sleep quietly. In those cases 
in which there is sufficient time for action between the beginning of the 



426 



DISEASES OF THE NERVOUS SYSTEM. 



aura and the unconsciousness, the paroxysms can very commonly be 
arrested either by mechanical or by medicinal means. If the aura be 
properly situated, the patient should be taught to grasp the limb firmly 
with the hand, or to encircle it with a tight band; usually the aura 
will be unable to pass the constriction. When the attack commences as 
a local spasm, forcible breaking of this spasm by stretching the part 
occasionally suffices. Amyl nitrite will in most if not in all cases, if 
promptly inhaled, arrest the fit ; ten minims of it in pearls, or in a little 
vial, should be carried in the pocket of the patient, and crushed or 
emptied upon the handkerchief and deeply, inhaled at the first inception 
of the aura. This mode of treatment seems to be entirely free from 
danger. 

The general management of the epileptic should be both hygienic and 
medicinal. Moderate exercise, intellectual and physical, with abundant 
sleep, should be strictly enjoined. In the young it is extremely impor- 
tant that the education go on, and that obedience, discipline, and self- 
control be taught. Over-study, of course, will do harm, but moderate 
study may be of service. So far as possible, the epileptic should conform 
in his daily life to the habits and customs of his class, and every effort 
should be made to prevent that withdrawal of the patient from society 
and business which the fear of publicity or of physical injury during the 
fit, and a false sense of shame, tend to produce. It is much better to take 
the risk of the convulsion occurring in an inconvenient position than 
unnecessarily to seclude the patient. 

The diet of the epileptic should be chiefly, but not altogether, vegetable. 
Abstinence from meat, which has been advocated by some authorities, is 
certainly of no value, and flesh may be taken twice a day in moderate 
quantities without any evil results. Tobacco, tea, and coffee are forbid- 
den by authorities, but when used in moderate quantities probably do no 
harm to the adult. 

The number of the older anti-epileptic remedies is in exact propor- 
tion to their worthlessness ; valerian, artemisia, belladonna, zinc oxide, 
copper sulphate, silver nitrate, and even borax, — which has been recom- 
mended comparatively recently, — are of no value.* 

The only remedies which we have seen do positive good in epilepsy are 



* The changes in the recurrence of the paroxysm and in the paroxysm itself in 
an epilepsy are so irregular and so apparently causeless, and the effects of mental 
impression so powerful in temporarily affecting the return of the fits, that the 
greatest care is necessary in deciding as to the value of individual remedies. Having 
a large ward of about fifty epileptics under my care, I kept all of them for a length 
of time without specific remedies, and then administered the bromides and after- 
wards borax. Under the bromides the weekly aggregate number of fits was reduced 
to about one-third of what it had been. The borax was given in as large dose as 
could be borne without gastro-intestinal disturbance, but caused no perceptible 
decrease in the number of fits per week. (H. C. W.) 



FUNCTIONAL NERVOUS DISEASES. 



427 



antipyrin, antifebrin, sulphonal, and the bromides. The value of sul- 
phonal is very slight ; it should be used only as a temporary expedient 
when for any reason it is necessary for a time to withdraw the more potent 
remedies. Antifebrin has distinct power in some cases ; its action seems 
to be closely allied to that of antipyrin, but in our experience it has been 
less efficient. In rare cases antipyrin, given by itself in doses of from 
ten to fifteen grains a day, acts most happily, and there are a few indi- 
viduals in whom it is preferable to the bromides. There seems to be 
no way of clinically determining in any individual case except by trial 
whether antipyrin given alone will suit or not. The chief value of the 
drug is in its being a coadjutor of the bromides. 

Of all the remedies against epilepsy the bromides are the most 
serviceable. Although Albertoni has shown by direct experiment that 
they diminish decidedly the irritability of the cerebral cortex in the 
motor zone, they are palliative rather than curative, and act only while 
present in the cortex. They do not remove the tendency to epileptic 
attacks, but antagonize the action of such tendency, and must therefore 
be in most cases administered continuously for many years after the 
occurrence of the last fit. The potassium, sodium, lithium, and ammo- 
nium bromides have been chiefly used. Of these potassium bromide 
has been most employed, but there is no reason for believing that it 
is superior to sodium bromide. Lithium bromide has yielded in our 
hands results not distinguishable from those produced by potassium 
bromide : having no advantage over the latter salt, and being more 
expensive, it is less available. On the other hand, strontium and am- 
monium bromides have very distinct superiority over the older bromides 
in being less apt to produce either physical or nutritive depression. It 
is possible to produce with either of them bromism, but the acne rash, 
the fetid breath, and the general nerve- depression are certainly less in 
proportion to the anti- epileptic effect than with potassium bromide or 
even a mixture of the older bromides. Both ammonium and strontium 
are stimulants to the circulation, whilst potassium is a powerful depres- 
sant. The strontium salt differs from the ammonium salt in being di- 
rectly less active as a bromide, but in having a most happy effect upon 
the alimentary canal. It may be that it is an intestinal antiseptic, but 
certainly in some way it improves digestion instead of harming it. The 
best results have in our experience been obtained from a mixture of the 
two salts in the proportion of two of the ammonium and one of the 
strontium. 

It is a matter of great importance to obtain, if possible, some combina- 
tion which will enable us to reduce the amount of the bromides necessary 
to control the epileptic fits. The addition of one one-hundredth of a 
grain of atropine per day to the bromides sometimes is of service ; more 
rarely the inconvenience of dry mouth, etc., which it produces exceeds 
any advantage derived. On the other hand, antipyrin is an exceedingly 



428 



DISEASES OF THE NERVOUS SYSTEM. 



valuable addition to the bromides. Again, arsenic certainly has some 
power in lessening the severity of the skin eruption produced by full 
doses of the bromides. The combination of the mixture of ammonium 
bromide, strontium bromide, antipyrin, and Fowler's solution is invalu- 
able in epilepsy. Within the last two years we have in a number of 
cases added to this combination the fluid extract of Solanum carolinense. 
This drug given by itself has with us failed entirely in epilepsy, but in 
doses of a teaspoonful it has in a number of cases enabled the patient 
to get along with less of the bromides. Antipyrin should never be 
given in sufficient doses to produce cyanosis ; ten grains per day can 
usually be administered without the induction of any apparent effect for 
many months, but in from one to two years there is often to be noticed a 
disorder of the thermogenetic functions of the body, so that the patient 
is continually cold and has a tendency to extreme coldness of the ex- 
tremities, with colliquative sweating, requiring the withdrawal of the 
antipyrin. Sulphonal in a measure will replace the antipyrin, in daily 
doses of from ten to fifteen grains, but care is necessary to avoid its too 
protracted administration, for fear of chronic poisoning. As the bro- 
mides act by accumulation in the system, it is not necessary to give them 
more than twice in the twenty-four hours, — a great boon, since the 
frequent taking of medicine is extremely irksome. In the beginning 
of the course of treatment ascending doses should be used until the 
paroxysms are controlled or until the presence of acne, somnolence, or 
excessive weakness shows that bromism has been induced ; later in the case 
the effort should be to keep the patient just within the limits of bromic 
saturation, — i.e., of a distinct physiological manifestation of the drug. 

In 1894, Flechsig claimed extraordinary results in epilepsy from the use 
of opium and the bromides in the following manner. The opium is at first 
taken in the dose of three-quarters of a grain of the extract three times 
a day, and regularly increased until fifteen grains a day are ingested. 
After this has been kept up for six weeks the opium is suddenly with- 
drawn and the bromide given in very large doses (two drachms) for two 
months, when it is gradually withdrawn. Usually the cessation of the 
attacks begins when the bromide is given, the opium treatment having no 
immediate effect. 

In the rare instances of Jacksonian epilepsy occurring without demon- 
strable organic brain- disease, the question as to the propriety of the re- 
moval of the cortical centres which appear to be implicated in such a case 
cannot as yet be positively answered. A priori it is to be expected that 
removal would be followed by a sclerosis, and that any benefit achieved 
would be temporary. There is, further, the serious inconvenience of 
paralysis which may be permanent. The clinical results so far obtained 
are, on the whole, not encouraging. Nevertheless, in clear cases surgical 
interference may be tolerated, provided the whole situation has been 
carefully explained to the person or persons most interested. 



FUNCTIONAL NERVOUS DISEASES. 



429 



PERIODIC PARALYSIS. 

Definition. — A paralysis without obvious cause, apparently not of 
hysterical origin, coming on in repeated attacks of brief duration. 

Symptomatology. — A periodic palsy is occasionally produced by 
malarial poisoning, a paralytic attack representing an ordinary malarial 
paroxysm. A number of cases have been reported in which, without 
loss of consciousness or sensation, but with loss of the reflexes and of 
the electrical reaction of the affected muscles, paraplegia or paralysis 
of both arms and legs has come on in paroxysms, lasting a few hours, 
the patient being between the paroxysms apparently normal. In several 
instances more than one member of the family suffered ; and Shakovitch 
reports a case in which the father of the affected patient was said to have 
died from an increase in the frequency of attacks of the same disorder. 
Of the nature of these cases we have no knowledge. In malarial paral- 
ysis quinine should be very freely given (forty to fifty grains in the 
interval). 

LARYNGISMUS STRIDULUS. 

Definition. — A violent spasm of the larynx, attended with dyspnoea 
and a peculiar crowing sound, not dependent upon an infectious or a local 
inflammation, and recurring at irregular intervals. 

Etiology and Pathology. — The most common cause of this disorder 
is rickets (see Tetany, p. 441) ; but the attacks do occur in adults, in 
some cases replacing paroxysms of migraine, in others apparently repre- 
senting epilepsy, in others hysteria. 

Symptomatology. — The phenomena of a paroxysm of laryngismus 
stridulus are a sudden pallor, a violent laryngeal dyspnoea, greatly altered 
or suppressed voice, loud stridor, and, as the spasm relaxes, a peculiar 
crowing noise. Severe attacks, especially as seen in adults, may last some 
minutes, and be attended with great distress and excitement, the subject, 
with extended arms, anxious, cyanosed face, bent- forward body, wide- 
opened mouth, and straining muscles, laboring for breath, now clutching 
at the throat, now tearing open the clothes in an agony. Death may seem 
imminent, but it is doubtful whether it ever occurs during a paroxysm. 

Diagnosis. — The laryngeal crises of locomotor ataxia closely simulate 
laryngismus stridulus, if indeed they should not be considered a form 
of it. Their nature is to be recognized by the recognition of the ataxia. 
Violent acute suffocation may be produced by hysterical (or other) paraly- 
ses of the abductors of the larynx, but in this affection the voice remains 
almost unchanged, and, although the inspiration is highly stridulous, the 
expiration is nearly noiseless. 

Prognosis. — The prognosis depends upon the cause of the disorder ; 
in epileptoid cases the paroxysms may continue for years. 

Treatment. — Amyl nitrite, ether, or chloroform may be inhaled 
during the paroxysm. The treatment between the paroxysms is that 



430 



DISEASES OF THE NERVOUS SYSTEM. 



which is appropriate for the condition underlying the attacks : phospho- 
rus in the rachitic cases ; bromides in the epileptoid cases ; etc. 

CONVULSIONS. 

Convulsions are symptomatic conditions which have been discussed in 
various portions of this volume, but their practical importance seems to 
warrant a brief return to the subject. 

In any case of convulsions to which the practitioner is called it is 
necessary to decide, first, whether the convulsion is hysterical, tetanic, or 
epileptiform. For the discussion of the diagnostic points in hysterical 
and tetanic convulsions, see pages 407, 424, and 199. 

In the epileptiform convulsion it must first be decided whether the 
convulsion is isolated or one of a series. If it is one of a series, the case 
is some form of epilepsy. (See page 423.) The isolated convulsion may 
be the first one of the series, but is in most cases the outcome of animal, 
vegetable, or mineral poisoning, or of peripheral irritation. In the adult 
it is most commonly due to a toxseinia, which in the majority of cases is 
uremic or alcoholic, but which may represent some other poisoning. 
Peripheral irritation, especially gastric irritation, does in rare cases cause 
convulsions in adults. 

In young children the convulsion very often marks the commence- 
ment of some exanthematous disease or of a severe pneumonia ; but per- 
haps more frequently it is a reflex convulsion, due to an irritation caused 
by teething, or by indigestible substances in the gastro- intestinal tract. 
The nature of a convulsion ushering in scarlet or other malignant fever 
can usually be recognized by the peculiar expression of illness and the 
general vital depression which attend it, and by the disturbances of the 
temperature, aided in some cases by knowledge of exposure to contagion. 
As, however, the diagnosis is frequently impossible in all cases of acute 
convulsions, the gums of the young child should be carefully examined, 
and if they be found swollen and inflamed should be lanced. Further, 
unless the case be a clear one, it should be a uniform practice to adminis- 
ter at once an emetic by the stomach, or to give a hypodermic injection of 
apomorphine. Especially is this routine proper because gastro-intestinal 
irritation in a susceptible child may cause so much vital depression and 
fall of temperature as to simulate the oncoming of a systemic fever. A 
dose of castor oil should be administered after the action of the emetic. 
The convulsion itself may be met by the free administration of the bro- 
mides, the extremely careful use of chloral, or, in severe cases, the in- 
halation of ether. The hot bath is useful in all forms of convulsions of 
children unless there be high bodily temperature. If there be high tem- 
perature it may be replaced by the tepid or the cold bath. We have 
seen children who had ceased to breathe and were apparently dead, as 
the result of violent gastro-irritation, recover by the use of artificial 
respiration carried out in the hot bath, the emetics which had failed 



FUNCTIONAL NERVOUS DISEASES. 



431 



to act producing free vomiting as soon as the bodily temperature was 
raised and the accumulated carbonic acid pumped out of the lungs. 

LOCAL SPASMS. 

Local convulsions, clonic or tonic, may occur within any nerve terri- 
tory,* but, unless distinctly due to cortical brain lesion or to hysteria, 
are very rare except in the face, the neck, and the trapezius muscle. 

Facial Spasm, Tic, Convulsive Tic, Painless Tic. — Clonic contractions of 
the facial muscles very often accompany trigeminal neuralgias or neuritis, 
constituting Tic douloureux, or painful tic ; but facial spasm may come on 
without obvious cause, or may be produced by distal irritations, espe- 
cially of the female genitals, and may follow a violent fright or other 
emotional nerve-storm, or even, it is said, traumatisms of the nerve 
or of the cerebrum. No lesion can usually be discovered after death ; 
rarely can any change be detected in the cortex. 

Facial cramp is usually unilateral, and may be confined to any muscle 
or affect the whole group supplied by the facial nerve. It usually occurs 
in paroxysms of tonic contraction, in which the eye is tightly closed, the 
forehead deeply wrinkled, and the nose and mouth drawn strongly to 
the side. With these tonic contractions, or replacing them altogether, 
are clonic movements. The attacks, which are less severe during abso- 
lute quiet, are greatly intensified by excitement, by efforts at chewing or 
speaking, and often by a blast of cool air. Blepharospasm is a tonic con- 
traction limited to the muscles that close the eye ; blepharoclonus is a 
similar clonic contraction. In these, and occasionally in other forms 
of facial spasm, strong pressure upon the place at which some branch, 
especially the supraorbital, of the trigeminal escapes from the skull, will 
often suddenly end the attack. When the muscles of the inner ear are 
affected, tinnitus aurium may be produced. 

Torticollis, contraction of the sterno-cleido- mastoid muscle, is in its 
most ordinary form rheumatic 5 the nature of such a case is to be recog- 
nized by the violent pain produced by passive efforts at motion of the 
head or by pressure on the affected muscles. Congenital torticollis is no 
doubt often due to injuries during birth, but its frequent association with 
irregular facial development indicates that at times it has a deeper origin, 
the nature of which is obscure. It may not be noticed for a long time 
after birth, when, on examination, the sterno-mastoid on the affected side 
will be found hard, shortened, and distinctly atrophied. In some cases 
the trapezius muscle is also involved. 

Spasmodic torticollis occurs both as tonic and as clonic spasms. When 
the contraction is tonic the occiput is drawn towards the shoulder of the 
affected side, the face is rotated towards the opposite shoulder, and the 
chin is raised ; an involvement of the trapezius increases the drawing of 

* For study of localization in any case, see the discussion of paralysis of periph- 
eral nerves in Chapter VI., Section II. 



432 



DISEASES OF THE NERVOUS SYSTEM. 



the head towards the affected side and raises the shoulder. In the clonic 
variety of the disease the contractions recur at very short intervals, and 
usually involve the trapezius muscle. Not rarely the splenius and even 
the muscles of the back of the neck are involved. Rotary spasm of the 
head (obliquus capitis muscle), and nodding spasms (the deep recti capitis 
muscle), sometimes complicate or replace the torticollis. 

Unless some point of irritation can be found, or the case is syphilitic 
or hysterical, the prognosis in these various spasms should be very 
guarded. Blepharospasm and clonus usually depend upon disease of the 
conjunctiva or of the eyelids, and disappear when this is cured. In the 
great majority of cases treatment is of no avail ; bromides, conium, 
aconite, hyoscine, and all the spinal sedatives may be tried seriatim, 
almost invariably with equally little result. The local applications of 
electricity and massage rarely do other good than to keep up the morale 
of the patient. The treatment should be, first, the up-building of the 
patient's health by the rest-cure or other measures adapted to the 
individual case ; second, the continuous, merciless use of the actual 
cautery. We have seen permanent cure obtained by such use in cases 
certainly not hysterical nor rheumatic. The burning should be repeated 
as often as the effects disappear. The very cautious use of tartar emetic 
ointment will sometimes serve advantageously in maintaining the effects 
of the burn. It should always be remembered that torticollis or facial 
spasm may be the only apparent outcome of a cerebral syphilis, under 
which circumstances the effect of antispecific medication is immediate. 
Various mechanical devices have been proposed for the relief of the 
patient ; all of them are of doubtful utility. The spinal accessory and 
other nerves have been frequently cut, with the effect of substituting 
paralysis for spasm. Often the spasm has returned, evidently after the 
reuniting of the nerve ; and still more frequently have the contractions, 
not long after the operation, appeared in the opposite side. 

ST. VITUS'S DANCE. 

Definition. — A non-febrile disease, not necessarily dependent upon 
demonstrable organic affection of the nervous system ; usually occurring 
in childhood ; characterized by generalized choreic movements and loss 
of nerve-power. 

Synonymes. — Chorea ; chorea minor ; chorea of childhood. 

Etiology. — Neuropathic heredity, luxury, poverty, whatever lessens 
the robustness of the nervous system of the child, predisposes to chorea. 
The disease is much rarer among negroes than among whites 5 is more 
frequent in girls than in boys ; about four-fifths of the cases occur 
between the fifth and the fifteenth year. 

Chorea, like other diseases connected with nervous exhaustion, is in 
the northern United States much more frequent in the spring, probably 
on account of the lowered nerve-tone produced by the long winter. So 



FUNCTIONAL NERVOUS DISEASES. 



433 



large a proportion of the sufferers from chorea are of the rheumatic 
diathesis, and so frequently does chorea develop from or into rheumatism 
or alternate with that disorder, that there must be some relationship 
between the two affections. What this relationship may be is at present 
unknown. Various authorities have recently maintained that the chorea 
of childhood depends upon the presence of a poison in the blood ; and the 
relation of chorea to rheumatism corroborates this view. Pianesi asserts 
that the disease is of bacillary origin, and that he isolated a bacillus 
which inoculated into the dog produced chorea. On the other hand, the 
sudden development of the disease by a powerful emotion does not seem 
compatible with the idea that it is of necessity due to a toxemia. 

Nevertheless, the view of Thiboulet, somewhat broadened, is very 
plausible, and in general accordance with the natural history of the 
disorder. This is that a chorea may be due to various poisons acting 
upon a nervous system which is predisposed to the disease. Chorea 
might thus be defined as a peculiar condition of the whole nerve-tract, 
capable of being produced by various poisons, and also by other disturb- 
ing agencies, such as violent emotion or anatomical alterations ; the latter 
perhaps due to wide- spread, minute thromboses. The action of these 
causes is favored by the existence of a peculiar predisposition of the 
nervous system to become choreic under their influence. 

Chorea is prone to recur, — not because one attack predisposes to an- 
other, but because a pre-existing foundation weakness renders the nervous 
system liable to be easily thrown off its balance time and again. 

Morbid Anatomy. — Various lesions have been found in the brain and 
in the spinal cord after death from St. Vitus' s dance, such as minute 
cerebral embolism, softening, interstitial proliferation, and hyperplasia of 
the neuroglia. F. C. Turner found in five cases of chorea that the nerve- 
cells in the Eolandic region were swollen and opaque. The ganglionic 
cells of the spinal cord have been found shrivelled, with an abnormally 
granular protorjlasm and an obscuration of their nuclei. H. C. Wood 
has found similar lesions in the brain and cord of choreic animals, but 
only in the later stages of the chorea. Examination of animals killed at 
various stages of the process shows that in the beginning no change can 
be detected, but a little later the cells are incapable of being stained and 
the nuclei are absent. The processes then become detached, and finally 
the cells are reduced to irregular, globose, crumpled masses. 

It must be remembered, however, that chorea may be developed in 
a few minutes from fright, and is usually recovered from in a few weeks ; 
hence it is absurd to suppose that it is necessarily based upon serious 
organic change of the nerve-centres. Moreover, even in cases of fatal 
chorea, competent observers have failed to find alterations in nerve- 
centres. 

Since choreic movements may originate in either the brain or the 
spinal cord, and the condition of the knee-jerks in the choreic child 

28 



434 



DISEASES OF THE NERVOUS SYSTEM. 



(see below) demonstrates that the ganglionic cells of the cord are in 
an abnormal state, it seems clear to us that the* basal lesion of St. 
Vitus' s dance is a change in the nutrition of the ganglionic structures 
of the whole cerebro-spinal axis. Structural changes sufficient to be 
detected by the microscope may not result, or pronounced alterations 
may follow. 

As has been pointed out by H. C. Wood, depression of the inhibitory 
spinal function is an important feature of chorea, the choreic exaggera- 
tion of voluntary movements occurring because of the failure of Setsche- 
now's inhibitory nerve-centres to arrest motor discharge from the spinal 
cells at the instant when it must cease in order that the motion be ex- 
actly as desired. It was found in Dr. Wood's experiments upon dogs 
that drugs which, like belladonna, depress spinal inhibition greatly ex- 
aggerate choreic movements, whilst drugs which, like quinine, stimulate 
spinal inhibition greatly lessen these movements. 

It must not be taken for granted that the pathology of true St. Vitus' s 
dance, or chorea of childhood, is that of all forms of chorea. The choreic 
movements may occur from diseases of any portion of the motor tract, 
and there can be no doubt that multiple emboli of the cerebral cortex 
and other gross lesions of the brain may produce a chorea. 

Symptomatology. — The invasion of this disease may be sudden or 
gradual. The attack may come on in the midst of apparent health, but 
ordinarily it is preceded by languor, irregular action of the gastrointes- 
tinal tract, and a pronounced nervous irritability. The motor disturbance 
may be first indicated by a peculiar restlessness of the child, who is not 
rarely punished for fidgeting. The true choreic movements usually appear 
first in the fingers, and shortly afterwards in the face, and spread until 
they involve the whole body. In severe attacks the arms are in almost 
constant movement, the fingers opening and closing, the wrists flexing and 
extending, and the elbow-joints in almost incessant activity, so that every 
imaginable position of the hand and arm is rapidly taken and lost. 
During the violence of the disease it is impossible for the child to control 
the movements of the arm sufficiently to dress or feed himself, or to per- 
form any act requiring precision of motion. At this time the legs are 
similarly affected, so that walking is gradually interfered with, or may be 
rendered impossible. The steps are irregular, jerking, often with lateral 
movements, now rapid, now slow, and if progression occur at all it is 
zigzag and uncertain. The face and head are no less affected : there is 
a constant, ever- changing distortion of the countenance, giving rise to 
fleeting expressions of sadness, terror, grief, rage, etc., and to grimaces 
innumerable. The mouth is opened and shut, the corners jerking up and 
down: the tongue is protruded, or sometimes moved rapidly in the mouth 
so as to produce a peculiar clacking sound. Articulation grows indistinct, 
the child speaks irregularly and badly, perhaps only in monosyllables, and 
finally the voice may be converted into a succession of irregular, unintel- 



FUNCTIONAL NERVOUS DISEASES. 



435 



ligible sounds. In very bad cases mastication becomes almost impossible, 
and even the muscles of deglutition are involved, so that the child is 
unable to swallow at the proper moment, and the food is spluttered and 
spilled about. The head itself is moved rapidly to and fro, backward and 
forward, sometimes laterally, sometimes in perpetual rotation. In the 
most violent cases all the muscles of the body are in a condition of furious 
action. The rolling, twisting movement of the trunk, and the perpetual 
beatings and thrashings of the extremities, render it almost impossible 
for the patient to lie in bed unless fastened down, and the utmost care 
is necessary to prevent severe bruises and excoriations of the skin. The 
knee-jerks in chorea are usually diminished or altogether absent, but on 
reinforcement are apt to be above the norm, — an indication that the usual 
spinal overflow from the brain-impulses for voluntary movements does 
not meet with the normal resistance, or, in other words, that there is 
weakness of the spinal inhibitory function. 

The respiratory muscles are the last to be affected, but cases have been 
reported in which hiccough, crowing inspiration, irregular respiratory 
rhythm, and other evidences of choreic action of the respiratory muscles 
were abundantly present. The choreic movements cease at night, or at 
least during sleep, but in the most severe cases by keeping the patient 
awake they produce an insomnia which constitutes an additional factor 
in the rapid wearing out of the strength and the bringing about of a fatal 
result. 

In chorea there is a peculiar nervous irritability often associated with 
apathy, which is almost characteristic, and which in bad cases is accom- 
panied by a loss of power of fixing the attention upon any one subject for 
a length of time, as well as by a weakness of memory. Hallucinations are 
very rare, and usually indicate that a chorea is hysterical. They may, 
however, occur in typical St. Vitus' s dance. In fatal cases the mental 
disturbances are very pronounced ; there may be even an acute dementia ; 
sometimes the patient is seized with maniacal delirium, which is always 
of exceedingly serious import. 

The heart- muscle may participate in the choreic disturbance. Chronic 
valvular lesions or acute endocarditis may give rise in chorea to mitral 
murmurs, but such murmurs are frequently heard in cases in which there 
is no distinct anaemia, no cardiac disease, and no permanency of the 
murmur after recovery from the chorea. Moreover, these murmurs vary 
from hour to hour, at times entirely disappearing ; and fatal cases have 
been reported in which no valvular lesion was found at the autopsy, al- 
though cardiac murmurs had existed during life. These murmurs must 
be due to irregular choreic contractions of the chordae tendinere prevent- 
ing the proper closure of the heart- valves. 

The course of chorea is always slow. Barely is recovery complete 
under five weeks ; it may be delayed for months. In some cases the 
condition is permanent. Usually, however, the child finally gets entirely 



436 



DISEASES OF THE NERVOUS SYSTEM. 



well. Death is exceedingly rare in the uncomplicated St. Vitus' s dance 
of childhood. 

Diagnosis. — The recognition of the existence of chorea is so easy as 
to need no further discussion. Care is sometimes necessary to avoid mis- 
taking an hysteria for an acute chorea. The most important distinc- 
tions are the rigidity and the tendency to rhythmical movements in the 
hysterical cases. The choreic neurosis is, however, so closely allied to the 
hysterical neurosis, and in some cases the symptoms of the two disorders 
are so intermingled, that it may be equally correct to speak of a case as 
one of choreic hysteria or one of hysterical chorea. 

Prognosis. — The obstinacy of a case of chorea is usually in direct 
proportion to the severity of the symptoms ; but, as the mildest cases 
sometimes prove extremely obstinate, the prognosis should always be 
guarded as to time, although a final complete recovery is to be expected. 
According to Guillemand, two and a half per cent, of all the cases prove 
fatal ; death, however, is extremely rare in children. 

Treatment.— The hygienic treatment of St. Titus's dance is the use 
of rest, fresh air, exercise, careful feeding, and tonics to restore the 
lowered nerve-tone. Great care must often be taken that the feeble child 
does not overexercise ; indolence rather than activity must usually at first 
be urged upon the choreic. Many hours a day ought ordinarily to be 
spent on the bed, while in severe cases a rest-cure treatment may be neces- 
sary. The child should be kept in the open air as much as possible, 
in a hammock, reclining chair, carriage, etc., according to the circum- 
stances of the case. The food should be nutritious, but not stimulating, 
thoroughly digestible, and given in as large quantities as the alimentary 
canal will assimilate, — milk and farinaceous articles, with a restricted use 
of meat and of sugar. Bitter tonics and alcohol in small quantities may 
be administered to increase the activity of the digestive organs, whilst 
cod-liver oil and iron, if well borne, may be employed as nutrients. The 
bitter vegetable purgatives are valuable if given only in such doses as will 
keep the digestive tract thoroughly cleaned out and stimulated. 

Drugs which depress motor activity will check choreic movements, but 
are only palliative. They accomplish no permanent good except by pro- 
curing rest and sleep. The bromides are not very effective, are distinctly 
depressing to the nutrition of the nervous system, and are to be used only 
under peculiar circumstances. Chloral will, for the time being, quiet 
almost any choreic movements 5 especially is it active when combined 
with morphine 5 and in all cases of chorea threatening life a combination 
of these drugs, in the proportion of ten grains of chloral to one-eighth of 
a grain of morphine, should be given at night in such amounts as may be 
necessary to procure quiet sleep. Trional may at times be substituted for 
the chloral. 

There are three drugs which have a specific permanent curative effect. 
Arsenic is extraordinarily effective : it should always be given by itself, 



FUNCTIONAL NERVOUS DISEASES. 



437 



so that its dose can be altered independently of that of other remedies, 
and must be administered in ascending doses up to the limit of toxic 
action. To a child five years old may be given three drops of Fowler's 
solution in milk after meals, the dose being increased every third day one 
drop until there is distinct puffiness of the face or gastro-intestinal dis- 
turbance, when the medicine may be temporarily withdrawn. Cimicifuga 
sometimes succeeds after the failure of arsenic. A freshly prepared fluid 
extract, having a strong odor of the drug, should be given in increasing 
doses until it causes headache or vertigo. Thirty minims may be the 
commencing dose for a child nine years old. 

Led to experiment by his belief that quinine is a stimulant to the 
inhibitory function of the spinal cord, and that failure Of spinal inhibi- 
tory power is a large element in the development of the choreic move- 
ment, H. C. Wood found that in dogs choreic movements are immediately 
arrested by moderate doses of quinine, and subsequently he experimented 
with the drug upon choreic children. The alkaloid is certainly of great 
value in many cases, but must be given in very large doses. In those cases 
in which quinine does good there is an extraordinary tolerance of it, so 
that it is almost impossible to produce cinchonism. Thus, Wood gave as 
much as one thousand grains in a month to a child of twelve years with- 
out cinchonism, but with the cure of a chorea of two years' standing. 

REFLEX CHOREA. CHOREA OF PREGNANCY. 

Definition. — Local or general chorea due to some peripheral irri- 
tation. 

Any form of chorea, from the most purely localized to that which 
closely simulates a St. Vitus' s dance, may be produced, in a person having 
a predisposition, by a peripheral irritation. Among these irritations may 
be mentioned intestinal parasites, diseased teeth, neuromatous tumors, 
nasal deformities or diseases, and irritation about the genitalia. In any 
case, therefore, of persistent choreic movements, it is essential for the 
practitioner to examine thoroughly for some point of irritation, and, if 
such be found, to remove it as soon as possible. The very serious chorea 
which occurs during pregnancy may be looked upon as a form of reflex 
chorea, due to the irritation of the foetus acting upon a nervous system 
predisposed to chorea perhaps by inheritance, perhaps by the nervous 
exhaustion produced by hydremia and other disturbances of pregnancy. 

As death is not infrequent in the chorea of pregnancy, due to the 
extremely violent and incessant movements depriving the sufferer of 
sleep and causing a rapidly progressive exhaustion, no time should be 
lost in bringing the patient under the influence of chloral and opium, 
aided by antipyrin and the bromides. It is essential also to maintain the 
bodily forces by moderate stimulation and high feeding. If the symptoms 
continue, the general consensus of obstetrical opinion is in favor of the 
production of abortion before the patient's strength is too much exhausted. 



438 



DISEASES OF THE NERVOUS SYSTEM. 



CONVULSIVE CHOREAS. 

Definition. — Affections with violent choreic movements which do 
not simulate complicated purposive acts and are not attended with loss 
of consciousness. 

For the convenience of the student, it is purposed here to discuss 
certain groups of cases in which the symptoms, although more or less 
similar, are of diverse origin. 

Hysterical Chorea. — Any form of movement may occur in hysteria, but 
the choreic movements of hysteria are usually rapid and more or less 
rhythmical, and are frequently seen in limbs already distorted by hys- 
terical contractures. The rhythmic spasm of hysteria may affect any 
portion of the body, giving rise in the face to all forms of grimaces, 
with or without the simultaneous thrusting out of the tongue, or, when 
attacking the muscles of the larynx and of respiration, causing various 
strange sounds. The so-called electric chorea^ in which the whole body 
or a portion of it is the seat of a more or less rapidly repeated clonic 
peculiarly brusque spasm, resembling that produced by an electric shock, 
is probably always hysterical. 

Choreic Tic. — In this group may be included various cases of local 
chorea, including the so-called habit choreas, in which it is believed that 
the origin of the chorea has been in a habit which was at first controllable 
by the patient but afterwards became a fixed nervous manifestation. 
Some of these local choreas are certainly from the onset uncontrollable. 
The tic or spasm may involve a single nerve- distribution, or a wide- 
spread area ; may be irregular, having no apparent relation with life ; 
or may continue the form of a purposive act in which, perchance, it 
had its start. A brow may be lifted at intervals, an eye winked, a jaw 
dragged forward, a shoulder shrugged, a trick of gesture incessantly 
repeated, even a cough or a snuffle perpetually indulged in. When the 
paroxysm is wide- spread and accompanied by a diaphragmatic contrac- 
tion, which by forcibly expelling the breath produces some bizarre sound, 
the case may assume the appearance of an automatic chorea, but is in 
fact essentially different from those cases in which the movements are 
directed towards an end and are caused by a dominating impulse. 

The treatment of cases of choreic tic usually ends in failure, and must 
be chiefly hygienic. Antispasmodic remedies are of no value. 

Organic Choreas. — Cases in which the choreic movements are due to 
various organic diseases of the nerve-centres. 

In this group belong the pre-hemiplegic and post-hemiplegic choreas, 
also athetosis, and allied affections elsewhere considered. It seems 
necessary only to state farther that there is a form of chorea occur- 
ring in very old people (senile chorea) in which the symptoms resemble 
those of the St. Vitus' s dance of childhood, and are probably due to 
obstructive interference by diseased blood-vessels with the blood-supply 



FUNCTIONAL NERVOUS DISEASES. 



439 



of the ganglionic cells of the pyramidal tract. The prognosis is always 
very grave j but under the free use of tonics, high feeding, and alcohol 
we have seen the choreic movements disappear. 

AUTOMATIC CHOREA. 

Definition. — An affection in which paroxysms of apparently pur- 
posive actions occur independently of the will of the subject, as the result 
of an impulse which arises spontaneously in the individual, or which 
occurs in response to some impulse received from without the individual. 

The definition just given covers two classes of cases : the chorea major 
or chorea Germanorum of some authors, including the salaam convulsions 
(tic salaam), and the extraordinary affection described in America as the 
jumpers, in Southern Asia under the Malay name of latah, in Eastern 
Siberia as miryachit, and in France as tic convulsif (in part) and as Gilles 
de la Tourette's disease. 

Etiology. — The only cause that can be assigned for automatic chorea 
is an hereditary neuropathy. 

Symptomatology. — Automatic chorea may occur in acute violent 
outbreaks or may be a chronic condition. In the former case there are 
usually prodromes, such as melancholia, apathy, malaise, cardiac palpi- 
tations, cramps, etc. A paroxysm usually begins with a general excite- 
ment which affects all the nerve-functions. Thus, songs are sung, foreign 
tongues spoken, events described, poetical quotations given in eloquent or 
usually more or less incoherent ravings, which often seem entirely beyond 
the normal intellectual power of the individual. In the height of the 
paroxysm the affected person dances, sings, springs from the ground, 
rolls himself from side to side, hammers violently with the hands, stamps 
with the feet, or in a fury of motor excitement whirls with mad rapidity 
until, completely exhausted, he falls to the ground in a condition of 
unconsciousness. 

Chorea major may exist in a sporadic form or may be epidemic, as in 
the hysterical religious epidemics of the Middle Ages and in the per- 
formances which occasionally occur during revivals in camp-meetings 
in the United States and among the howling dervishes of Mohammedan 
countries. The epidemic disease must be looked upon as hysterical. 
Some of the sporadic cases are probably instances of epileptic automatism. 
It may well be that a morbid impulse (see p. 385) underlies many cases, 
such as those in which the attack consists in the person bowing repeatedly 
on entering a room or approaching an individual (tic salaam), or as that 
of a Philadelphia patient who would suddenly leap from his chair, seize 
his hat, jam it down on his head two or three times, and then throw it on 
the ground violently before going on with his business. 

The essential feature of lotah is an extreme excitability of the patient, 
so that an abrupt excitation by a sudden salutation, by a blow given, 
etc., causes violent disorderly actions conjoined with a condition of the 



440 



DISEASES OF THE NERVOUS SYSTEM. 



cerebro-nervous system which necessitates the repetition of voices or 
sounds (echolalia) or the ejaculation of some word, usually obscene (copro- 
lalia). In some cases the impulse of imitation is so great as to force the 
victim to repeat not only the spoken word, but also any act done by a 
by-stander. Very frequently the sudden nervous excitement is accom- 
panied by an excessive emotion, especially of fear, although such emo- 
tion may be entirely foreign to the ordinary nature of the individual. 
The disease appears to be hereditary. In the Jumping Frenchmen of 
Maine, described by Dr. George M. Beard, these phenomena were very 
pronounced, and were associated with a mental condition which required 
the jumper to obey a loud command, the act of obedience being accom- 
panied with an inarticulate cry of alarm. Dr. Beard tested the echo- 
speaking or repetition by reading portions of Latin and Greek, when 
the untutored jumper repeated the sounds of the words as they came to 
him in a quick, sharp voice, at the same time jumping or making some 
bizarre motion. 

There is no reason for believing that specific medicinal treatment is 
of avail in any automatic chorea. The general health should be built 
up, and an effort made to form the habit of self-control. 

HEREDITARY CHOREA. HUNTINGDON'S CHOREA. 

Definition. — An hereditary affection characterized by general cho- 
reic movements, and usually associated with other evidences of disturbed 
innervation. 

Etiology. — The only known cause is direct heredity. The asser- 
tion that if the disease fail to appear in one generation the remaining 
generations will remain free expresses a general but not invariable rule. 

Morbid Anatomy. — We have no determinate knowledge of the basal 
lesion of hereditary chorea, although it probably is some developmental 
departure from the norm in the nervous system. The lesions which have 
been found at autopsies have been so various that none of them can be 
considered essential. It is true that Greppin was led to believe, as the 
result of his own studies, that the histological basis of the disease con- 
sists in numerous focal groups, chiefly in the white substance beneath 
the cerebral cortex, formed of cellules having a nucleus with a highly 
developed nucleolus , and that Klebs found in one case somewhat similar 
foci in the same position. On the other hand, Cirincione and Mirto, and 
also Wharton Sinkler, failed to detect any such bodies in cases carefully 
studied by them. 

Symptomatology. — Hereditary chorea usually develops in middle 
life, although it has appeared at or even before puberty. The choreic 
movements resemble those of St. Vitus' s dance, but are more constant, 
more rhythmical, and less under the control of the will. While standing 
or sitting the patient is continually repeating the same irregular jerking 
movements. The walk is especially peculiar : for the first few steps it may 



FUNCTIONAL NERVOUS DISEASES. 



441 



be nearly normal, when suddenly it is interfered with by one leg being 
thrust violently forward and the other one being jerked up to it, so that 
the subject seems to go with a quick, short hop, almost like a dancing step. 
The course of the disease is exceedingly slow, and in some cases many 
years are required before the subject becomes unfit for physical labor. 
The mental condition is usually but not always abnormal. Excessive 
irritability, moroseness, melancholia, chronic mania, and dementia have 
all been noted. The reflexes are often exaggerated, but may be sluggish. 
The sensations are normal. In some instances there is a peculiar mus- 
cular stiffness. 

Hereditary chorea never gets well, and is in no way amenable to any 
known treatment. 

TETANY. 

Definition. — A disease consisting of tonic spasms, either continuous 
or paroxysmal ; usually symmetrical ; affecting especially the extremities, 
but often wide- spread or sometimes confined to one limb ; accompanied 
by disturbances of sensation, which may be severe, but never by uncon- 
sciousness, and not depending upon any known lesion of the brain, cord, 
or nerves, or upon hysteria. 

Etiology. — In the great majority of cases tetany is due to rickets.* 
Both in human beings and in dogs and cats it has often followed extirpa- 
tion of the thyroid. It is said to be directly produced by excessive lac- 
tation, by the puerperal state, by exposure to cold, by prolonged fatigue, 
by diarrhoea, by dilatation of the stomach, by the irritation of intestinal 
worms, by exposure, and even by the rheumatic diathesis or the infectious 
fevers, and by ergot, stale fish, and other poisons. Further, it is affirmed 
that it may result from excessive emotion and spread from patient to 
patient as an epidemic. Such epidemics have, however, probably been 
hysterical. 

Morbid Anatomy.— There is no demonstrable lesion in tetany. Some 
authorities assert that it may be due to the presence of a poison produced 
in the alimentary canal. Bouveret and Devic have isolated from the con- 
tents of dilated stomachs (of persons who had not had tetany) a convulsant 



* The nervous disturbances of rachitic children are : 

1. Insomnia. Sweating of the head. Great nervous timidity, so that they are 
easily affrighted. 

2. Face phenomena. 

3. Expiratory apnoea and laryngismus. 

4. General convulsions. 

5. Universal hyperidrosis. 

6. Trousseau's phenomena. 

7. Spontaneous tetany. 

8. Nystagmus and spasmus nutans. 

These nerve phenomena may occur in any combination or singly, and are all 
remarkably improved by the use of phosphorus, which acts by curing the rickets. 



442 



DISEASES OF THE NERVOUS SYSTEM. 



which they believed to be identical with Brieger's peptotoxine ; whilst 
I. Jacobson and C. A. Ewald obtained from the urine of a typical case 
of tetany a ptomaine-like body which disappeared when the patient was 
restored to health and which was believed to have been formed by 
bacteria. It may be that various poisons and diathetic conditions have 
the power of causing a similar condition of the nerve-centres. 

Symptomatology. — Typical tetany consists essentially of successive 
tetanic convulsive attacks separated by intervals of quiet and repose. 
The paroxysms may continue for minutes or hours, may cease gradually 
or abruptly, and may recur at intervals of hours, days, or weeks. Ar- 
thralgic pains, formication, or numbness in the hands, radiating pains 
in the fingers, temporary partial blindness, headache, sense of fatigue, 
etc., are assigned as occasional prodromes. Usually the spasms are most 
marked in the upper extremities, and sometimes are confined to them ; the 
fingers are often so drawn together as to form a cone. Earely there is a 
more accentuated flexion of the fingers, and still more infrequently the 
hand and the fingers are stiffly extended. The feet may be attacked ; 
sometimes cramps of the calf occur without distortion, but in other cases 
the feet are violently extended, with the toes pointing downward ; more 
rarely the feet are flexed. The thigh usually escapes, but spasm of the 
abductors and crossing of the feet have been noticed. Only in the se- 
verest cases are the trunk-muscles affected, but opisthotonos and menacing 
dyspnoea do occur. Even more exceptional than these are spasmodic 
closures of the jaw and distortions of the face. During the attack the 
pulse is usually accelerated ; the temperature may be subnormal, normal, 
or slightly elevated. The course of the disease may be painless. Some- 
times, however, neuralgic pains run along the nerves, and usually cramp- 
pains are present in the affected muscle. Anaesthesia and analgesia are 
ordinary phenomena. 

In some cases which must be considered at present as representing 
tetany the spasms are continuous, lasting without interruption for many 
weeks. Such cases appear chiefly among adults, and in our experience 
have been accompanied by anaesthesia and numbness, but not by actual 
pain. 

The knee-jerks in tetany may be increased or weakened. Anomalies 
of secretion, such as hyperidrosis, polyuria, albuminuria, and glycosuria, 
have been noted in some cases ; whilst redness and ©edematous swelling 
of the skin, urticaria, zoster, pigmentation of the skin, and a remarkable 
falling out of the hair and nails have been recorded. There are certain 
important and peculiar symptoms more or less characteristic of tetany, 
any, all, or none of which may be present. These are the Trousseau, 
the ChvosteJc, the Erb, and the Hoffmann symptom, so named from their 
respective discoverers. 

Trousseau discovered that if during the period of quiet the main nerve 
or artery of the limb were pressed upon firmly from two to three minutes 



FUNCTIONAL NERVOUS DISEASES. 



443 



tetanoid contractions would occur in the limb. Chvostek's symptom is 
due to an exaltation of the mechanical excitability of the motor nerves, 
so that if a nerve be struck with the fingers or with a percussion-hammer 
pronounced contractions will be produced in the tributary muscles. As 
this symptom is most frequent and most marked in the face, it is often 
spoken of as the face phenomenon. Erb's symptom is an increase of the 
electrical excitability of the motor nerves, which is shown to some extent 
with the faradic but is more marked with the galvanic current. Hoff- 
mann's symptom is the outcome of an increase of the mechanical and 
electrical sensibility of sensitive nerves, so that slight pressure or slight 
faradic or galvanic irritation will produce severe paresthesia throughout 
the whole distribution of a nerve. A similar hyperexcitability has been 
noted in the nerve of hearing. Of these symptoms, according to Krafft- 
Ebing, Erb's is the most frequent ; Trousseau's is present in not more 
than sixty per cent, of the cases ; whilst Chvostek's is comparatively rare. 

Latent Tetany. — Sometimes in rickety children the face phenomenon 
may exist without other symptoms, and sometimes tetanoid attacks may be 
produced by Trousseau's method when they do not occur spontaneously. 

Diagnosis. — The spasms of tetany are so characteristic that usually 
there can be no difficulty in making the diagnosis. The disease is at once 
separated from tetanus by the absence or late and feeble development of 
trismus, by the peculiar positions taken by the hands, and by the lack of 
intenseness of the symptoms. Trousseau's phenomenon is characteristic, 
and occurs in no other nervous disease ; but the peculiar nerve excitability 
may exist in tuberculosis and other conditions, although it is very rarely 
so pronounced as it often is in tetany. 

Prognosis. — Tetany almost always, unless dependent upon an irre- 
movable cause, such as extirpation of the thyroid, is recovered from. 
When it occurs during pregnancy it may continue until the birth of the 
child, and then disappear. The length of the attack depends upon the 
character of the cause. It is, however, essentially an enduring affection, 
usually continuing for some weeks or even months. 

Treatment. — In the treatment of tetany it is necessary to remove, if 
possible, the cause. Thus, in rachitic cases phosphorus should be admin- 
istered. In gastro- intestinal cases the stomach and intestines should be 
thoroughly emptied, and be kept as nearly normal as possible. Cases 
(rheumatic ?) have also been reported in which the whole attack was put 
an end to by a full dose of pilocarpine. 

In very bad cases it may be necessary to control the attacks by mor- 
phine and chloral. Hyoscine has recently been very strongly recom- 
mended, and would seem to be indicated by its physiological action. We 
have had no opportunity of testing it. The bromides, especially am- 
monium and strontium bromides, are often of great service. Warm 
baths and hot packs, either general or to the affected limbs, are sometimes 
very useful. Little is to be hoped for from electricity : the faradic current 



444 



DISEASES OF THE NERVOUS SYSTEM. 



will probably do more harm than good ; a very weak galvanic current 
passed from the centres upward rarely does good. 

Hygienic treatment looking towards the strengthening of the system 
should always be assiduously practised. 

PARAMYOCLONUS MULTIPLEX. 

Definition. — An affection characterized by paroxysms of clonic con- 
tractions chiefly of the muscles of the extremities. 

Etiology. — Most of the cases have originated in fright 7 and have 
occurred in male adults. Weiss asserts that he has seen several cases in 
one family. 

Morbid Anatomy. — Tambroni and Pieracini have recorded cases de- 
pendent upon organic lesions of nerve-centres. Other cases have been 
clearly instances of hysteria. Weiss maintains that out of fifty- one re- 
corded cases only thirteen were, really instances of the disease ; whilst} 
Mobius believes that Weiss' s own cases were, in fact, cases of hereditary 
chorea. 

Symptomatology. — The clonic spasms usually begin in the muscles 
of the legs. They may at first be controlled to some extent by the will 
and be not severe enough to prevent work. They are, as a rule, bilateral, 
and vary from fifty to one hundred and fifty in a minute. In the intervals 
between the attacks there may be tremors in the muscles. Sometimes the 
contractions are definitely rhythmical. They may involve the muscles of 
the back and of the abdomen, and become so severe as to make it difficult 
to keep the patient in bed. 

Prognosis and Treatment. — The cases usually recover, but fresh 
attacks at shorter or longer intervals are common. The treatment is 
that for hysteria and neurasthenia. 

paralysis agitans. 

Definition. — A disease of advanced life, characterized by tremors 
which continue during the waking hours and are associated with mus- 
cular weakness and rigidity. 

Etiology. — Paralysis agitans rarely occurs in persons under forty 
years of age, is most frequent between fifty and sixty, and is more 
common in men than in women. It is not distinctly hereditary, and 
can rarely be traced to an exciting cause, although it has been produced 
by violent fright, prolonged anxiety, exposure, and even physical injury. 

Morbid Anatomy. — None of the pathological theories which have 
been brought forward in regard to paralysis agitans have sufficient plausi- 
bility to require discussion here. 

Symptomatology. — The onset of paralysis agitans is usually insid- 
ious, but in occasional cases may be abrupt. A transitory tremor appears 
in the hand or foot, or even in one finger or toe. At first it can be con- 
trolled by an effort of the will, and is suspended by voluntary motion. 



FUNCTIONAL NERVOUS DISEASES. 



445 



Little by little, however, it becomes more fixed and more wide-spread, until 
at last it continues throughout the waking hours, during repose as well as 
during action, and is uncontrollable. From the limb first involved it 
usually passes to the limb of the same side, constituting the hemiplegic 
form, or, especially when it begins in the leg, it may cross to the oppo- 
site limb. The face is rarely attacked by the tremors, although in the 
later stage it is affected by the rigidity and takes on a peculiar fixed 
immovable, usually melancholy, expression. According to Charcot, the 
head is never directly affected, any apparent trembling of it being due to 
transmission of motion from the trunk ; but this is certainly too absolute 
an assertion. In the advanced stages of the disease the peculiar prone or 
forward position of the head and the weakness of the lips often produce 
a dribbling of the saliva. The speech at the same time becomes a little 
slow and labored, but is never profoundly affected. Neither eating nor 
swallowing is interfered with. The tremors are short, rapid, sometimes 
rhythmical, and in the fingers occasionally assume an appearance of 
purposive action, as though the patient were rolling something between 
the digits. Regular rhythmical sounds will often alter the rate of the 
tremor without the patient's being conscious of it. Violent muscular 
contractures never occur, but a peculiar rigidity develops, giving rise to 
the characteristic fixation of the affected parts, and especially to the 
statue-like rigidity of posture. 

In standing the trunk is inclined forward, with the face looking ob- 
liquely downward ; the forearms are usually flexed somewhat upon the 
arms, the hands a little bent upon the forearms, and the fingers partially 
closed, so that the hands assume a position similar to that in which 
the pen is held; hence the term " writing hand" as given by Charcot. 
The same tendency to flexion of the legs exists, so that in standing the 
knees are bent. Occasionally, peculiar distortions of the hands or other 
portions of the body may be met with. On attempting to restore the 
normal position of the parts the muscles usually offer but little resistance 
until the restoration is nearly perfected. 

Complete paralysis never occurs in paralysis agitans, but very early in 
the disease loss of endurance manifests itself, and it commonly increases 
until only brief muscular efforts are possible. 

An almost characteristic symptom is festination, — that is, a progressive 
increase in the rapidity of gait : apparently owing to the position of the 
body, the subject in walking thrusts one leg forward more and more 
quickly in order to prevent toppling over, so that the walk becomes more 
and more rapid, and in a little while in extreme cases may break into a 
run, which grows faster and faster, until the patient either falls or arrests 
his course by seizing hold of some stationary object. That the festination 
is not dependent simply upon the position of the body is shown by the 
facts that a normal gait sometimes exists in subjects who are strongly bent 
forward, and that in very rare cases there is a tendency in the patient to 



446 



DISEASES OF THE NERVOUS SYSTEM. 



run backward instead of forward. Sensibility is not usually markedly 
affected, nor is there suffering, except in the advanced stages from the 
perpetual sense of fatigue in the affected muscles, which may amount to a. 
severe aching. There is often a feeling of excessive heat, accompanied by 
continual sweating ; in such cases the central bodily temperature is normal, 
but according to Grasset and Apollinario there is an elevation of the sur- 
face temperature. Thus, these observers found that in the normal indi- 
vidual the surface temperature was 33.6° C, whilst in a case of paralysis 
agitans placed under exactly the same circumstances it was 36.8° €5. 
According to Eegnard, the elimination of urea is normal, that of the 
sulphates less than the norm. Cheron affirms that there is a constant 
increase in the excretion of the phosphates, which is characteristic and 
may precede the development of the tremors. 

Paralysis agitans requires many years for its full development, but, 
unless the patient dies of some intercurrent disorder, hypochondriasis, 
great depression of spirits, loss of intellectual power, general failure of 
nutrition, marked emaciation, marasmus, and finally death from exhaus- 
tion occur. 

Diagnosis. — Senile tremors may simulate paralysis agitans. In them, 
however, the head is especially affected, and there are usually tremblings 
of the tongue and lower jaw. It is stated that the loss of power, the 
rigidity and fixation of the limbs, and the peculiar gait and later evi- 
dences of general nerve degeneration of paralysis agitans may develop 
without the tremors. The diagnosis of such a case could be arrived at 
only after long watching. Blocq and Marinesco have reported a case with 
hemiplegic tremors, which was diagnosed as paralysis agitans, in which 
the lesion was a tumor in a cerebral peduncle.* 

Prognosis. — Eecovery never takes place in paralysis agitans. 

Treatment. — There is no specific treatment. The patient should lead 
a quiet regular life, with absolute avoidance of physical or mental labor. 
Electricity, which has been much used, has no real value. The hot bath 
is often of service as a palliative, especially in the advanced stages. 
Conium, hyoscyamine, cannabis indica, morphine, chloral, alone or in 
various combinations, may be useful for the purpose of procuring sleep, 
if necessary, or for giving relief. The formation of the narcotic habit, 
however, is always imminent. In our hands the best results have been 
obtained from hyoscine hydrobromate, given at night, or during the day 
when the tremors are excessively painful. 

TRAUMATIC NEUROSIS. 

Definition. — A condition of neurasthenia, usually with hysterical 
symptoms and local lesions, produced by severe injuries. 

Traumatic neurasthenia is so invariably associated with symptoms 



* Compt.-Eend. Soc. Biolog., v., 1893. 



FUNCTIONAL NERVOUS DISEASES. 



447 



which are of local origin, the direct result of the injury of the part 
affected, that it is necessary to speak of these complicating symptoms 
before discussing the main subject. A blow upon a muscle suspends its 
function without lacerating its structure, probably by a concussion of the 
nerve- endings. This condition is rare, except in the deltoid muscle, in 
which it is frequently produced by a fall. The treatment consists of 
acute antiphlogistic measures, followed when all inflammation has sub- 
sided by the injection of strychnine into the muscle, of the use of massage 
for the purpose of freeing the muscles and muscular fibre bundles from 
exudation, and of stimulating nutrition, with the application of that elec- 
trical current which will produce the greatest contraction of the affected 
muscles with the least pain to the patient. In cases of traumatic neuras- 
thenia the so-called traumatic back is very common. The condition may 
be produced by a direct blow, but is more commonly the outcome of a 
sudden jerk or wrench which produces a sprain of the fibrous tissues of 
the back and probably gives rise to a deep-seated inflammation, which, 
although primarily situated in the fibrous structure, may implicate peri- 
osteum and nerve-roots and produce very serious results. Directly after 
an accident the amount of injury to the back may not be apparent. The 
symptoms are tenderness more marked upon deep firm pressure than 
upon slight pressure, and restriction of movement by pain and by spasm 
of the erector spinse muscles. Reflex spasms may also be producible in 
the back muscles by jarring, or by pressing upon the head or the verte- 
bral column. As in other forms of sprain, rest is the basis of treat- 
ment of the traumatic back, and for the purpose of obtaining it and of 
relieving the effects of pressure the plaster jacket, or some other form of 
the Sayre jacket, is often very useful. To its employment in the ordinary 
manner may be added that originally suggested by H. C. Wood, which 
we have found very useful, especially when the traumatism is in the lum- 
bar region of the back. It consists- in swinging the patient many hours a 
day more or less completely from the upper of the two cones forming the 
human trunk. In carrying it out the patient should be suspended in the 
ordinary way for putting on the plaster jacket, and, when the first layer 
of the plaster jacket has been put in place, two broad, strong linen 
bandages, well wetted, are to be so arranged, one over each shoulder, that 
they shall form above a loop, whilst the ends hang down front and back 
below the plaster bandage. With new turns of the plaster bandage these 
vertical linen bandages are to be fastened in position, and afterwards the 
loose ends of the linen bandage are to be drawn up and firmly secured by 
further turns of the plaster bandage. Often by fastening such a jacket 
to the head-board the bed may be kept strongly inclined without incon- 
venience to the patient, but with a constant drag from the lower extremi- 
ties, separating the sore vertebrae. Severe counter- irritation is sometimes 
useful in traumatic back, and careful massage should always be tried. 
Etiology. — Eailroad injuries, falls from hatchways, press of steam 



448 



DISEASES OF THE NERVOUS SYSTEM. 



from exploding boilers, any violence acting npon the trunk through 
crushing local force or so as greatly to shake and shock the whole 
system, may produce traumatic neurasthenia, as may also sudden twists 
and wrenches of the back in railroad and other accidents. 

Symptomatology. — The symptoms of traumatic neurasthenia may 
appear at once after the injury or may come on insidiously. The sub- 
jective symptoms are malaise, loss of ambition, marked nervous irrita- 
bility, failure of the power of mental and physical labor, depression of 
spirits, occasional headache, pronounced tinnitus aurium, broken sleep, 
diminished sexual power, and general failure of health. Almost inva- 
riably to these symptoms are added various hysterical manifestations. 
Probably among these must be classed the extraordinary cerebral attacks 
which come and go often without obvious cause or explanation. Some- 
times these attacks resemble petit mal, in that they consist of short 
moments of unconsciousness ; sometimes the paroxysm is prolonged and 
consists of an active delirium, which may amount to a furious and aggres- 
sive mania. Often the patient has no remembrance of these attacks. 
Distinctly hysterical paroxysms are not rare. Neurasthenic vaso motor 
weakness is common, so that sudden flushings of the face and abrupt out- 
breaks of sweating are frequent. The muscular irritability is often greatly 
augmented ; the knee-jerks may be exaggerated, but vary from day to day, 
and become rapidly exhausted by re-excitation, or even by general bodily 
fatigue. Ankle-clonus is rare. Paradoxical contractions may often be 
produced in the anterior leg muscles by flexure of the foot, and the slight- 
est irritation may in some cases cause a general reflex contraction of the 
erector pilse muscle, with a consequent ' ' goose-flesh. ' ' The sexual power 
is commonly not altogether lost, but sexual irritability and weakness 
are usually shown in men by premature emissions. True diabetes, with 
its secondary results, may be present. 

Prognosis. — The course of this disorder is essentially slow, requiring 
years for recovery, which is apt to be imperfect. Death is very rare, 
unless the violence has been sufficient distinctly to compromise the nerve- 
centres. 

Diagnosis. — Owing to medico-legal complications, the first question 
to be asked in a case of traumatic neurasthenia is whether the symptoms 
are real or feigned, and, if real, how far they are exaggerated. It is next 
essential to determine, for the purposes of prognosis, the proportion of 
local diseases, of neurasthenia, and of hysteria. Purely traumatic hys- 
teria, the outcome largely of fright, yields usually to skilful treatment 
without very great delay ; whereas both the local disorder and the trau- 
matic neurasthenia, if well developed, are always very serious, requiring 
very long continued careful treatment, and in many cases remaining per- 
manent to a greater or less degree. It is essential, therefore, upon the 
witness-stand clearly to distinguish between a simple hysteria produced 
by an injury and the more serious condition. It must also be remem- 



FUNCTIONAL NERVOUS DISEASES. 



449 



bered that these neurasthenics are from the very nature of their cases 
more or less hysterical. 

It is farther necessary in cases as they present themselves to decide as 
to the involvement of the spinal cord j absolute loss of sexual power, 
paresis of the bladder, trophic lesions, and persistent uniform rigidity 
or a complete paralysis of any part are very strong evidences in favor 
of the spinal lesion. The same is true of an anaesthesia which is pro- 
nounced and not hysterical. 

Treatment. — Absolute rest in bed, with a very careful use of massage 
and electricity, and the administration of narcotics for the purpose of 
relieving pain, are the chief measures to be early practised in traumatic 
neurasthenia. Tonics are of very little value. With narcotics there is 
always the very grave danger of the formation of the narcotic habit. In 
the most successful case we have ever seen, a physician treated himself 
chiefly by drinking from three to four pints of strong ale daily, through 
extraordinary strength of character finally escaping the narcotic habit. 
The faradic current ordinarily irritates and does harm ; the continued 
galvanic current, passed from the centres to the periphery of the nerves, 
often is soothing, and perhaps permanently advantageous. The moral sup- 
port of the patient by care in the arrangement of the details of life, and 
by the semblance of medication, is often of the greatest practical impor- 
tance. Later the subject should be induced to settle down, preferably in 
a rural district, to quiet life, free from excitement and serious labor. Any 
fatigue usually aggravates the condition. 

CAISSON DISEASE. 

Definition. — A disease of uncertain pathology, occurring in those 
who work in compressed air. 

Etiology. — All reported cases have occurred in those who work in 
caissons or other chambers in which the air is highly compressed. As the 
abrupt passage from the caisson to the outer air is exceedingly dangerous, 
arrangements are usually made to have the pressure gradually reduced to 
the norm ; but no precautions have hitherto been completely effective. 

Morbid Anatomy. — No immediate autopsies are on record. Two 
months after exposure, Dr. Caspar W. Sharpless found foci of softening 
apparently due to minute hemorrhages and secondary inflammation. 
In other cases similar disseminated focal myelitis has been found. The 
theory that the symptoms are due to sudden evolution of compressed gas 
from the blood into the nerve-centres is plausible, but has not been proved. 

Symptomatology. — The symptoms of caisson disease usually develop 
in from half an hour to two hours after the return of the subject to the 
outer air. Violent pains occur in the limbs and in the hands, followed 
in a few minutes by progressive loss of motor and sensory power in the 
legs. Notwithstanding the anaesthesia may become complete, the pains 
continue, whilst headache, dizziness, double vision, incoherence of speech, 

29 



450 



DISEASES OF THE NERVOUS SYSTEM. 



mental aberration, and sometimes unconsciousness, rapidly develop. 
The patient may convalesce in a few days, or death may take place 
quickly with apoplectic symptoms, or may follow from paralytic bedsores 
and cystitis after some months. Usually, however, recovery occurs after 
a prolonged period of atrocious suffering and motor disablement. The 
treatment is expectant and palliative. 

HEAT EXHAUSTION. 

Definition. — A condition of profound exhaustion, with lowered bodily 
temperature, excessive sweating, and disturbed innervation, due to the 
combined action of heat and exertion. 

Symptomatology. — The symptoms of heat exhaustion vary from 
those of intense tire to those of collapse. In severe cases the attack 
may develop rapidly, even with the absolute abruptness of a syncope, 
the symptoms being unconsciousness or semi-unconsciousness, muttering 
delirium, great restlessness, facial expression of collapse, rapid, feeble, 
scarcely perceptible pulse, and a temperature which may be as low as 
95° F. 

Diagnosis. — With a knowledge of the history it is hardly possible to 
mistake heat collapse for the collapse due to organic disease. The impor- 
tant points in the diagnosis are the temperature and the absence of evi- 
dences of internal hemorrhage and of heart or other chronic diseases. 
From true thermic fever the case is at once set aside by the temperature. 

Treatment.— The free immediate use of external heat, — if possible, 
the hot- water bath, — the hypodermic injection of atropine, strychnine, 
cocaine, and digitalis to dry the skin and to stimulate the heart and vaso- 
motor system, and a very moderate internal use of hot alcoholic drinks 
and of ammonia, will invariably lead to cure, unless some chronic disease 
underlies the condition. 

THERMIC FEVER. SUNSTROKE. 

Definition. — Acute fever produced by exposure to heat. 

Etiology. — Thermic fever is always dependent upon exposure to heat, 
natural or artificial. Owing to interference with evaporation, a hot moist 
atmosphere is much more dangerous than is dry heat. Hence sunstroke 
is rare in dry climates and frequent in tropical lowlands, as well as in 
sugar-refineries, laundries, and similar places. It may occur in the night 
as well as in the day. Yery powerful as predisposing causes are lack 
of acclimatization, excessive bodily fatigue, and intemperance. Males 
are more frequently affected than females, because of their more frequent 
exposure. 

Morbid Anatomy. —Owing to the intense heat of the body, post-mor- 
tem changes begin at once after death, and of such nature were most of the 
lesions described as occurring in sunstroke by early writers : moreover, the 
post-mortem findings are greatly modified by the treatment and the time 



FUNCTIONAL NERVOUS DISEASES. 



451 



of death. If the patient have died during an acute sunstroke, with high 
temperature, and the post-mortem be made at once, the left heart will be 
found contracted, the right heart usually engorged, the semi-fluid blood 
collected in the venous trunks, and the arterial coats, or it may be the 
whole body, marked with petechia or stained with decomposing blood. 
In some cases the blood has an acid reaction. (Wood. ) Many years ago 
H. C. Wood proved that the cause of the symptoms and the structural 
lesions in thermic fever is simply excessive heat. The history of the 
development of an attack is probably at first a slow rise of the bodily 
temperature, produced by the inability of the system to get rid of the heat 
which is formed in it ; after a time the inhibitory heat-centres at the base 
of the brain, which control the formation of bodily heat, become exhausted 
by effort or by the fever itself ; and as a consequence of the removal of 
inhibition there is a sudden increase of the formation of heat, with a cor- 
responding up -bound of the bodily temperature and consequent uncon- 
sciousness from the paralyzing influence of the heat upon the cerebral 
cortex. All the higher tissues of the body are affected directly by the 
excessive temperature, and death from a pure heat paralysis of the re- 
spiratory centres may quickly occur. 

Myosin (the substance whose coagulation produces post-mortem rigid- 
ity) coagulates at about the maximum temperature of sunstroke. After 
severe exertion the muscles, including the heart, contain an excess of a 
myosin which is more prone to undergo coagulation than is normal myosin. 
In this fact is found the explanation of the extraordinary positions of the 
corpses of those who have been killed in battle : instantaneous death has 
been followed by an equally instantaneous coagulation of the myosin of 
the general muscles, so that the body has been frozen in the attitude at 
which life was stopped. The heart is in the centre of the bodily heat : not 
rarely in tropical battles, especially when troops have been charging up- 
hill, the overstrained heart has been suddenly arrested by the coagulation 
of its myosin, and the man has fallen on his face in instantaneous syncopal 
death. 

Symptomatology. — The mildest form of sunstroke is the subacute 
variety, which was described by the physicians of India many years ago 
under the name of ardent continued fever, and which was especially studied 
in America by Professor John Guiteras, who showed that the so-called 
typhoid fever of Key West is in most part this affection. The symptoms 
are a continued fever without local disease, with a tendency to weakness 
and the typhoid state, and various disturbances of function. In India, it 
is stated, the cases are apt to end in the sudden development of the severest 
type of thermic fever and death ; in America they usually recover under 
treatment. 

Sunstroke commonly begins with abrupt complete unconsciousness, al- 
though prodromes, such as general distress, a great burning heat, and chro- 
matopsia, or colored vision, do occur. With the unconsciousness there are 



452 



DISEASES OF THE NERVOUS SYSTEM. 



usually muttering delirium, great muscular restlessness, partial convul- 
sions, or violent epileptiform attacks ; sometimes there is quiet coma with 
relaxation. The surface of the body is always hot ; at first dry, it may 
later be bathed in a profuse perspiration ; the face is flushed and the eyes 
are suffused ; the pulse may be bounding and full, but is almost invariably 
compressible, and if not originally rapid and feeble becomes so as the case 
progresses. Vomiting and purging are very common. The whole body is 
apt to exude a peculiar odor, which is especially strong in the faecal dis- 
charges. The characteristic symptom is a temperature which is rarely 
below 108° and may reach 113° F. The urine is scanty, sometimes albu- 
minous, not rarely suppressed. The breathing is more or less labored and 
irregular. The pupils are dilated. In most cases some response can be 
obtained by shaking the patient, except very late in the disorder. Death 
may occur in about half an hour, but usually is postponed for a longer 
period 5 it is ordinarily the result of a slow simultaneous failure of respi- 
ration and of heart action, but may be due to asphyxia, or in very acute 
cases to cardiac arrest. 

A condition similar to sunstroke may develop in so-called cerebral 
rheumatism and other affections with very high temperature. As was 
first pointed out by Dr. Comegys, many of the cases of so-called cholera 
infantum occurring in young children in the large cities of America 
during the summer months are really forms of thermic fever. The 
symptoms in such cases are high fever, intense thirst, rapid pulse and 
respiration, vomiting, purging, and more or less pronounced evidences 
of cerebral disturbance, such as insomnia, headache, contracted pupils, 
delirium, and finally coma ending in death. 

Diagnosis. — In a certain sense the diagnosis of thermic fever is made 
at the moment the temperature is found to be 108° F. or upward, because 
such temperature produces a thermic fever whether it (the temperature) is 
due to external heat or not. The diagnosis of thermic fever in the narrow 
sense of the term requires, however, a knowledge of the exposure to heat. 

Prognosis. — The prognosis in thermic fever depends chiefly upon the 
time at which treatment commences. If the high temperature has lasted 
a sufficient length of time to produce alteration in the nerve-centres and 
in the blood, the symptoms may not be interrupted by the reduction of the 
temperature. Almost invariably, if the temperature be reduced immedi- 
ately after the subject falls, consciousness will return and the case go on 
favorably, if relapses be guarded against. The persistence of nervous 
symptoms after a reduction of the temperature is of the most serious 
import. 

Treatment. — When exposure to high temperature cannot be helped, 
it is essential that the bodily health be maintained and that all excesses 
in labor or in pleasure be avoided. The diet should be largely farina- 
ceous, and the emunctories should be kept active by the eating of fruit, 
and by the free use of cold water and of lemonade, and of mild salines if 



FUNCTIONAL NERVOUS DISEASES. 



453 



necessary. Ice- water, if taken in large quantities, may do harm by sudden 
chilling of the stomach, and drunk at meals may interfere with digestion ; 
but ingested in moderate quantities at short intervals between meals it does 
great good by reducing the general temperature and aiding free perspira- 
tion. All alcoholic drinks are to be avoided, except that a little claret or 
red wine may often with advantage be added to the water taken, to make 
it more acceptable to the gastro-intestinal tract and more active in pro- 
moting perspiration. Cold baths should be used frequently, especially if 
at any time the bodily temperature be found to be rising. 

The use of cold is the basis of all treatment of sunstroke. According 
to Guiteras, in subacute or continued thermic fever the best plan is to 
wrap the patient in a dry sheet, lift him into a tub of water at a tem- 
perature of 80° F. , and then rapidly cool this water by means of ice, the 
immersion continuing from forty-five to fifty-five minutes, according to 
the effect upon the mouth temperature. The patient is then to be placed 
upon a blanket, the skin partially dried, and the body covered. Guiteras 
states that it is very important to avoid currents of air blowing upon the 
patient, and to have the bath given in a small warm room j also that in 
most cases great advantage is to be obtained by giving moderate doses of 
whiskey, with from twenty to thirty minims of tincture of digitalis, about 
twenty minutes after the bath. Guiteras never found it necessary to give 
more than two baths in the twenty-four hours, but in some cases the baths 
had to be used for many days. 

In acute thermic fever the bodily temperature is to be reduced at once 
by the means most convenient : there should be no waiting for the sum- 
moning of a physician. The patient should be carried into the shade 
and have cold affusions over the face and body, or should be put at once 
under a pump and be pumped on, or should be plunged into a bath of 
ice- water. City ambulances, when it is practicable, should be furnished 
with ice and antipyrin, so that when the sunstroke patient is reached 
treatment may be commenced at once. In giving the cold bath a non- 
registering thermometer should be in the mouth or the rectum of the 
patient, the axillary temperature not being a true indication of the tem- 
perature of the body. The patient should be removed from the bath 
when the bodily temperature reaches 101° F., since it is not rare for the 
fall of temperature to continue after removal from the bath. Alcohol, 
and strychnine and digitalis hypodermically, may be useful even while 
the patient is in the bath, when the symptoms seem to point urgently to 
them ; antipyrin is a valuable remedy for the purpose of preventing rise 
of temperature after the patient has been taken out of the bath. 

When there is in sunstroke a hard pulse, and the symptoms are 
essentially those of a congestive apoplexy, free venesection is some- 
times useful, especially as it is a powerful reducer of bodily temperature. 
When the convulsive tendency is very acute, morphine may be given 
hypodermically. 



454 



DISEASES OF THE NERVOUS SYSTEM. 



As soon as may be after sunstroke the patient should be removed to a 
cool atmosphere, and should be kept upon a light farinaceous diet, and 
generally treated as though in danger of an acute meningo- encephalitis. 
Especially if there be any tendency to headache, or cerebral flushings, 
local blood-letting followed by blisters and other forms of counter-irritation 
should be used. If the headache when the patient first comes to himself 
be intense, general venesection may afford a means of relief. 

Sequelae. — Cerebral distress or pain, with failure of general vigor, 
dyspeptic symptoms, and various indications of disturbed innervation 
frequently occur after thermic fever. In pronounced cases the pain in the 
head is more or less constant, but subject to exacerbations, and is some- 
times associated with pain and stiffness in the back of the neck. "With 
it there may be vertigo, decided failure of memory and of the power of 
fixing the attention, insomnia, and excessive nervous irritability. When 
this is the case there is usually a marked lowering of the general health, 
with loss of strength, and the peculiar invalid look which characterizes 
severe chronic disease. Epileptic convulsions, with very pronounced 
evidences of severe cerebral inflammation, occur in rare cases. The one 
symptom which is always present, and which is diagnostic in these cases, 
is the inability to withstand heat : not only are the symptoms greatly 
exaggerated, it may be to the point of severe illness, during the summer 
months, but in most cases headache and great distress are produced by 
going into a hot room even in winter. The lesion underlying the condition 
just spoken of is a chronic irritation of the brain membrane and cortex, 
passing, if the case be severe enough, into pronounced chronic meningitis 
with greater or less involvement of the cortex. 

The treatment is, first, absolute avoidance of any exposure to even 
moderate heat, combined with intellectual and physical rest ; second, the 
treatment of non-specific chronic meningitis, — i.e., local bleedings and 
Insistent, merciless counter-irritation, especially by means of the actual 
cautery, combined with the internal administration of mercurials and 
potassium iodide in very small continuous doses (one-fiftieth grain of 
corrosive sublimate, one to two grains of iodide, three times a day); 
third, restriction to a largely farinaceous, non-irritating diet, and careful 
attention to all minor symptoms as they arise. 

OCCUPATION NEUROSES. 

Definition. —Localized disturbances of motion produced by the ex- 
cessive use of groups of muscles in the daily occupation of life. 

Etiology. — Occupation neuroses are almost indefinite in number. 
Piano-forte-play er's cramp, violinist's cramp, telegrapher's cramp (chiefly 
among those who use the Morse machine), dancer's palsy (especially af- 
fecting the calf-muscles), hammer palsy (occurring chiefly among gold- 
beaters), chisel cramp (among mechanics), etc.. are ordinary forms : but 
seamstresses, tailors, money-counters, watchmakers, engravers, knitters, 



FUNCTIONAL NERVOUS DISEASES. 



455 



etc., are occasionally disabled by peculiar occupation neuroses. The 
occupation neurosis is not caused by severe muscular efforts, but by the 
excessive repetition of movements which require fine coordination. 

Morbid Anatomy. — The pathological condition in the occupation 
neuroses is probably one of local neurasthenia, with habitual congestion 
and irritability of the affected centres. 

Symptomatology. — The characteristic symptom of the occupation 
neuroses is the coexistence of the disablement for the habitual fine action 
with preservation of muscular power. Thus, a man who cannot grasp 
the pen may wield with ease a fifty-pound dumb-bell. In 1868, Moritz 
Benedict distinguished three forms of occupation neuroses, — the paralytic, 
the spasmodic, and the tremulous. Whilst typical cases of these varieties 
are occasionally seen, usually the symptoms are mixed. According to our 
observations, paralysis is in most cases the dominant symptom, tremor the 
least developed. 

As writer's cramp is the most common of the occupation neuroses, we 
shall consider it as the type. In it there is usually some painful fatigue 
in the arm, which may be associated with slight formication and numb- 
ness, and rarely with tenderness over the nerve-trunks. Any attempt at 
writing produces intolerable pain in the part, often accompanied by a 
sense of stiffness, or even by a distinct muscular resistance when the effort 
is made to grasp the pen. In severe cases the sense of fatigue continues 
even after long resting of the arm, and there may be with it a distinct pain 
between the shoulders. The stiffness and occasional cramp of the fingers 
around the pen reveal the nervo-muscular irritability, in the paralytic 
form of writer's cramp ; but in the spasmodic form irregular muscular 
contractions are the most prominent manifestations. At first slight spas- 
modic movements of the thumb and first finger produce an occasional 
irregular stroke in the writing, but as the disease progresses, occasional 
sudden extension of the finger causes the pen to be dropped, or by a 
spasmodic action of the opponens pollicis, with abduction and coincident 
flexion of the index finger, the pen is rapidly moved from the paper, or 
occasionally a violent spasmodic flexion of all the concerned fingers holds 
the pen as in a vice. 

In the tremulous form of writer's cramp the tremors may become so 
excessive that the pen follows them rather than the directions of the 
will, and no trace is left upon the paper but irregular, undulating, and 
angular strokes. According to our observations, tremors are especially 
common in telegrapher's cramp. 

Prognosis. — Occupation neurosis almost invariably gets well, pro- 
vided that absolute rest from the occupation can be secured for a great 
length of time. Eecovery is, however, always slow, and the disablement 
has a pronounced tendency to return upon repetition of the habitual acts. 

Treatment. — In writer's cramp, as in other occupation neuroses, it 
is essential for the subject to cease doing the act which has produced the 



456 



DISEASES OF THE NERVOUS SYSTEM. 



peculiar exhaustion. The direct treatment of the part is very unsatis- 
factory. ~No internal medication is of any use, except as it may benefit 
the general health of the patient and overcome any neurasthenic tendency. 
Massage seems to be of distinct value. Electricity has been very largely 
employed, and is by some authorities strongly commended, by others 
spoken of with despair. It seems, in fact, to do good in some cases, but 
more often its influence is not perceptible. Faradization may do harm, 
as the muscles are commonly irritable ; it rarely, if ever, does good. The 
best application is the long- continued use of a mild current of galvanic 
electricity passed down the nerve of the affected member, of just such 
strength as to be distinctly but not painfully perceived. A small positive 
pole should be placed over the nerve-trunks in the groove of the inside 
upper arm, whilst the hand rests upon a large well- wetted sponge con- 
nected with the negative pole. 

Clerks and others who are required to use the arm excessively in 
writing should employ a light pen-holder, half an inch in diameter (cork 
preferable), with a blunt-pointed steel pen or a quill pen, and should adopt 
the free- writing method, in which the movement is chiefly from the shoul- 
der and the words are formed without lifting the hand from the paper. 
Various writing-machines have been invented, but are unsatisfactory. In 
many cases the solution of the practical difficulties is to be found in the 
use of a type- writing machine. When it is necessary that the writing shall 
be continued at all hazards, the left hand may be employed. In writing 
with it, it will be found easier to reverse the lines, — that is, to write with 
the slope from left to right. Usually the left hand soon develops the dis- 
order, even though the greatest care be taken not to overwork it. 

HEADACHES. 

Headaches not due to diseases of the brain or its membranes can be for 
practical purposes classed as toxemic ; sympathetic, due to some periph- 
eral lesion ; and nervous, including various headaches not in the two 
other groups. It is not possible by a study of the headache itself to 
decide its nature, so that the examination of a case of persistent head- 
ache should be thorough and absolute. 

Toxaemic Headaches. — Of the toxsemic headaches the most impor- 
tant are secondary to diseases of some organ, such as the kidney, the 
heart, or the lungs, or are malarial, rheumatic, litha^mic, alcoholic, caf- 
feinic, or gastric. Any disease which interferes with the aeration of the 
blood, or with its purification by the emunctories, is liable to produce 
headache, whose cause is to be made out only by finding the disease. 

Brow ague is an intense pain occurring in more or less regular par- 
oxysms, usually in the immediate neighborhood of one supraorbital fora- 
men, often associated with fever, sweat, or other malarial indications. Its 
nature is to be recognized by its periodicity and by its yielding to very 
large doses of quinine (forty grains). 



FUNCTIONAL NERVOUS DISEASES. 



457 



Rheumatic headache is usually a heavy ache, but may be associated 
with sharp neuritic paius. It is to be recognized by the existence of a 
rheumatic diathesis, by the effect of weather, and by the marked soreness 
of the scalp which usually accompanies the pain. In doubtful cases the 
therapeutic test with salicylates should be made. 

Gouty or lithwmic headache is often dull, heavy, and worse in the morn- 
ing ; but it may occur in very acute paroxysms at irregular intervals, 
and be associated with vertigo, staggering, or even epileptoid spells, so 
as to lead to the mistaken diagnosis of organic brain lesion. It is prob- 
able that in some of the cases there is really a gouty meningitis, with or 
without deposit of urates. The diagnosis is to be reached by exclusion 
and the recognition of the existing diathesis. The treatment is that of 
irregular gout. 

The caffeinic headache is especially common in women of neurotic 
temperament, but occurs also in men. For some unknown reasons there 
are numerous individuals who can drink without suffering tea, but can- 
not take coffee ; others, fewer in number, who can use coffee, but not 
tea. The worst cases of caffeinic headache occur in sewing- women and 
factory-girls who are underfed and stimulate themselves for work by tea. 
The caffeinic headache ceases when total abstinence from caffeinic drinks 
has been enforced for a month. 

Gastric headache, when due to acidity, may occur in violent paroxysms 
and dizziness, and yields rapidly to ammonium and sodium bicarbonate. 
The headache of indigestion with hepatic torpor (biliousness) is usually 
frontal, may be occipital, and is often associated with defective vision, gid- 
diness, and great depression of spirits. 

Sympathetic Headache. — Headache may result from almost any 
peripheral irritation, but is extremely common from eye-strain, and occa- 
sionally occurs from disease of the nose. The headache of eye-strain is 
often frontal, perhaps more frequently occipital, but varies greatly in char- 
acter, and may even be indistinguishable from a migraine. It is usually 
aggravated by the use of the eyes, is apt to be severe in the morning after 
an evening spent in a place of amusement, but is to be diagnosed with 
certainty only by finding and correcting the optic defect, when the pain dis- 
appears. Usually it is relieved almost at once by paralyzing vision with 
atropine and employing dark glasses. The character of a nasal headache 
may often be detected by the tenderness of the inner wall of the orbit 
when pressed upon by the finger, or by the pain caused by touching the 
middle turbinate bone with a probe. In many cases, however, the nasal 
significance of headache can be determined only by removing the nasal 
disease. 

Nervous Headaches. — In this group may be put the headache of 
anaemia and exhaustion, the congestive headache, the hysterical headache, 
and certain rare headaches whose cause cannot be elucidated, and which 
may therefore be spoken of as essential. The headache of anaemia and 



458 



DISEASES OF THE NERVOUS SYSTEM. 



exhaustion is very often rather a sense of weight and distress than a true 
pain. It may, however, be very severe, and be accompanied by so much 
flushing of the face and conjunctiva as to mislead the practitioner into 
supposing that there is a true brain congestion. It is commonly relieved by 
stimulating foods, such as strong beef- essence, or by milk-punch or other 
nutritive alcoholic drink. The headache of acute cerebral hyperemia is 
usually due to some demonstrable cause, such as traumatism, exposure to 
the sun, malarial fever, etc. Its nature is to be recognized by the general 
excitement of the circulation, the strong pulsations in the carotid, and the 
tendency to coma and delirium. Headache in hysteria may take on any 
form, but may be considered as characteristic when it is a pain situated 
in the middle of the top of the head, in a point so small as almost to be 
covered with the tip of the finger (clavus). 

MIGRAINE. 

Definition. — An hereditary paroxysmal headache, without obvious 
cause, usually appearing at puberty and gradually disappearing after the 
age of fifty. 

Etiology. — The only known cause for this disorder is heredity. 

Morbid Anatomy. — Some authorities are inclined to believe that 
migraine is a vaso-motor neurosis, and Eulenberg has described two varie- 
ties, one with vaso-motor spasm, as shown by pallor of the face, dilated 
pupil, and hard temporal artery ; the other with evidences of vaso-motor 
relaxation, such as redness and heat of the face, injection of the conjunc- 
tiva, lachrymation, and inflammation of the affected ear, with free lateral 
sweating j but as the disease occurs in America these two varieties cannot 
be made out. 

Of the basal nature of migraine we have no knowledge. The parox- 
ysms are evidently of the nature of nerve-storms, which suggested many 
years ago to Trousseau that migraine has a relation to epilepsy. There 
are undoubtedly cases in which migraine and epilepsy coexist : others in 
which the two forms of paroxysms seem to replace each other. Never- 
theless it is in the highest degree improbable that there is any relation 
between ordinary migraine and the more serious disorder. Cases indi- 
cating relationship are probably not more than one in five hundred, and 
no interchangeability in heredity can be traced, epilepsy not being de- 
monstrably more frequent in families having a strong migraine heredity 
than in the general community. The best explanation of the rare cases 
is, therefore, the coexistence of two neuroses. The relations, on the other 
hand, between migraine and gout seem very close, almost all cases seen in 
Philadelphia, at least, having a distinct gouty family history. 

Symptomatology. — Migraine occurs in paroxysms, which may be 
separated by a few hours or many months. The attack is usually pre- 
ceded by malaise, chilliness, and a sense of languor, or more rarely by a 
condition of exhilaration. In most cases the pain commences in the fore- 



FUNCTIONAL NERVOUS DISEASES. 



459 



head near the supraorbital foramen, and gradually increases in intensity 
until it becomes unbearable. It is variously described by sufferers as 
boring, throbbing, or shooting, and is sometimes situated in the occip- 
ital region. After a time repeated vomiting occurs, with relief which may 
be immediate or gradual. The whole paroxysm lasts from five hours to 
two or even three days, and is often accompanied with intense intolerance 
to light and sound and distinct hysterical manifestation. In some cases 
there is aphasia during the height of the paroxysm ; vomiting may be 
absent. 

An attack of migraine may be ushered in by an aura, which suggests 
that of epilepsy, although in most cases it takes the form of a disturbance 
of special sense. Earely a peculiar bitter or very disagreeable taste, or, it 
may be, a peculiar odor, like that of osmic acid, marks the coming on of 
a paroxysm. The auditory prodrome, which is extremely rare, has been 
variously described as like the sound emitted from a marine shell applied 
to the ear, or as a gurgling similar to that which is heard when water 
enters the ear during bathing. 

Of the special- sense auras the most important is the peculiar visual 
disturbance which has given rise to the special name of ophthalmic migraine 
(hemiopia periodica). The most frequent disorder of sight is an ambly- 
opia, accompanied by vivid scintillations of light passing zigzag over the 
field of vision. Hemiopia, either monocular or binocular, sometimes 
lateral, sometimes vertical, may replace the amblyopia ; or a central 
scotoma may be the chief phenomenon. Earely during the attack these 
alterations of vision change one into the other, and still more rarely are 
they accompanied or replaced by distinct hallucinations. We have noted 
megalopsia. 

An attack of migraine is usually attended with emotional depression, 
which may amount to a brief melancholy. O. Berger affirms that there 
is with the attack hyperesthesia of the skin of the face, at least so far 
as the sense of locality and the electric senses are concerned, but there is 
commonly no hyperesthesia to touch, and no nerve -tenderness even at 
the point of nerve- emergence. Firm pressure often gives relief. 

Diagnosis. — The diagnosis of migraine, usually easy from the history 
of the case, is to be confirmed by the exclusion of other causes of the 
attack and by a study of the family history. 

Prognosis. — Migraine is practically incurable, but abates after middle 
age, and is often much ameliorated by treatment. 

Treatment. — The treatment of migraine consists primarily and 
chiefly in building up the general health of the patient. The higher the 
health the fewer the attacks. The most scrupulous care must be employed 
to search out all peripheral irritations, especially eye-strain, and to correct 
gout or other diathetic tendencies. The continuous administration of 
cannabis indica is often of great service in lessening the number and se- 
verity of the fits. A known extract should be given in ascending doses 



460 



DISEASES OE THE NERVOUS SYSTEM. 



until it produces mild symptoms of intoxication, and then a dose just 
within the limit of the full physiological dose should be administered three 
times a day for months. Caffeine, antipyrin, and antifebrin are often use- 
ful in alleviating the pain in a migraine attack, and will in some persons 
even abort a paroxysm. Guarana, which has been much employed, 
depends for its activity upon caffeine. Of all palliatives the most cer- 
tain is the combination of deodorized tincture of opium with potassium 
bromide (twenty minims to sixty grains). Unlike opium given by itself, 
this mixture rarely causes after-nausea and depression. The danger of 
forming the narcotic habit is never to be lost sight of in a disease so 
chronic as migraine. 

SLEEP, ITS DISORDERS AND ACCIDENTS. 

Sleep, stupor, and coma are not, as has been held by some, essentially 
diverse conditions, but are the outcomes of different degrees of complete- 
ness in the suspension of the function of the cerebral cortex, and are 
not to be separated by any fixed lines, every gradation being found in 
the sick-room between the lightest slumber and the deepest coma. Yet 
for discussion we may arbitrarily divide suspensions of consciousness into 
sleep, that condition of unconsciousness in which the subject is readily 
aroused, and when aroused is easily kept awake by ordinary external 
stimulations or by his will-power ; stupor, that condition in which the 
subject is aroused with great difficulty and when left to himself relapses 
into unconsciousness ; and coma, that state in which it is impossible by 
external irritation to restore consciousness. 

For the purposes of treatment it seems essential to have a proper phys- 
iological understanding of the causes and nature of these grades of uncon- 
sciousness. Certain neurologists hold that the lapses from consciousness 
are due to changes in the circulation ; but no proof of this has ever been 
given. It is true that during sleep there is more or less pronounced cere- 
bral anaemia, which on awaking is replaced by turgescence of the cerebral 
vessels. It is a universal law that cessation of functional activity is imme- 
diately followed by lessening in the amount of blood in the part. We 
conceive, therefore, that the sleep or cessation of functional activity is the 
cause of the bloodlessness, and not the bloodlessness the cause of the sleep. 
Insomnia may be connected either with excessive anaemia or with excessive 
congestion of the cerebral cortex. One theory of the mechanism of sleep 
is that the latter is due to the formation by the processes of life during 
the waking moments of some poison which acts upon the cerebral cortex. 
This theory, again, is a purely speculative one. At present it is best 
simply to consider that it is a function of the cortical brain- cells when 
exhausted to pass into a condition of inactivity, during which their power 
of further effort is recuperated. 

The disorders of sleep may be divided for our present purposes into 
— first, abnormal wakefulness ; second, abnormal somnolence or morbid 



FUNCTIONAL NERVOUS DISEASES. 



461 



sleep 5 third, accidents or groups of symptoms which occur during sleep 
and which are not elsewhere spoken of in this book. 

Abnormal Wakefulness. — In some cases of insomnia the subject is 
simply unable when bedtime comes to go to sleep ; in other cases he 
goes to sleep readily, but wakes in two or three hours and is unable to 
slumber again. The latter form of insomnia is rarely the precursor of 
severe mental affections, but is often very obstinate. 

As insomnia may exist as a prodrome, or as a symptom, of a general or 
local organic brain -disease, and as it also may be produced by diseases of 
various organs other than the cerebrum, and as, further, even in its most 
aggravated form, it may be the chief symptom of a cerebral disturbance 
and have no connection with any organic disease, it is essential in every 
case of insomnia that a very careful study be made of the whole indi- 
vidual, in order that the cause of the sleeplessness may be discovered, or 
else that by exclusion the case may be diagnosed as one of simple func- 
tional disorder. Insomnia not only produces great suffering, but in itself 
may lead to severe mental disease, so that its treatment is a matter of great 
importance. 

In the treatment of insomnia it is essential to remove the cause : if 
any organic disease be found in the brain or elsewhere, its careful treat- 
ment is imperative. A frequent cause of simple insomnia is lithsenxia ; 
where this is the case relief may often be obtained by the use of the 
salicylates. 

Insomnia produced by an active determination of blood to the head, 
that is, by active cerebral hyperemia, is certainly rare except as a pre- 
cursor of acute periencephalitis or other severe organic brain- disease. 
It may, however, develop as the result of excessive mental labor. Its 
nature is to be recognized by the fact that it accompanies an increased 
power of work, and often an exhilaration of spirits ; the subject being 
able to go on night after night and produce work in quantity and quality 
above his normal powers. Such insomnia is always a very dangerous 
condition, and should be immediately treated by the cessation of work, 
by local blood-letting, by counter-irritation, and by full doses of seda- 
tive narcotics. The bromides are useful ; hyoscine hydrobromate is a 
specific. Unless with the local hyperemia there is a condition of gen- 
eral loss of power, the combination of aconite with the other remedies 
may act most happily. Sometimes in the insomnia of acute congestion 
sleep may be procured by giving the patient at bedtime a mustard foot- 
bath ; a much more efficient procedure is to direct the patient to sit in 
a bath of very hot water and have a cold douche on the head from three 
to five minutes. 

When insomnia is connected with local or general neurasthenia, rest- 
treatment modified to the individual case may be of great service. It 
would appear that in the majority of cases of ordinary simple insomnia 
there is a basal exhaustion ; at least, it is not infrequent that food taken at 



462 



DISEASES OF THE NERVOUS SYSTEM. 



bedtime, or when the patient wakes sleepless in the middle of the night, 
has a very beneficial effect. Bouillon, thickened with sago or lentil 
flour, oyster-soup, hot milk-punch, Mellin's Food, any easily digested hot 
food, may be used. Brandy or whiskey in a little hot water, strong ales, 
and other alcoholic drinks in some cases are very efficient. A half-ounce 
of whiskey or a single glass of very hot water, taken on awaking in the 
middle of the night, will often cause the wakeful subject to go to sleep 
within five minutes. 

In the regulation of the habits of a person suffering from insomnia, 
careful study must be made not only of the general nature of the case, but 
also of the idiosyncrasies of the patient. Thus, in some persons massage 
before the time of sleep has a distinctly quieting influence, whilst upon 
others it acts as an excitant. Tire very frequently causes wakeful nights, 
but there are some cases in which exercise brings sleep. In all cases of 
insomnia it is essential that intellectual activity and emotional excitement 
during the latter third of the day be avoided ; that the supper taken be 
light ; that the patient sleep by himself or herself in a well-ventilated 
apartment, and that no caffeinic drinks be used after the morning meal. 

In the treatment of insomnia narcotic drugs are to be avoided as far as 
possible, except in acute cases, when, if the symptoms have developed as 
the result of a sudden emotion or other strain, it is sometimes possible by 
exerting a strong influence for a few weeks to break up the habit of in- 
somnia and then gradually to withdraw the remedy. If the insomnia be 
so severe that hypnotic drugs become necessary, two rules must be observed 
in their administration : first, always to use the least powerful narcotic 
which will achieve the desired object ; second, not to use a single narcotic 
(unless it be a bromide) continuously for more than from one to two weeks, 
so as to prevent as far as may be the system from becoming accustomed to 
it, and also to avoid the danger of chronic poisoning by it. Opium is the 
worst of the whole class. The bromides are the least injurious, but rarely 
suffice, although they are very useful in combination, and often lessen 
the amount required of more powerful remedies. Hyoscine never produces 
chronic poisoning, nor, so far as we know, the hyoscine habit, and when it 
suits the individual case is, therefore, valuable. It should be given at bed- 
time. Sulphonal is one of the least harmful of all the narcotics, provided 
that its administration be not kept up too long. When there is any brain 
weakness, as in very old or paretic patients, it may produce mental con- 
fusion or continuing drowsiness the day after its administration. A num- 
ber of deaths have been produced by a sudden outburst of poisoning when 
sulphonal has been administered for several months. It is so insoluble 
that the compressed pill readily passes through the intestines without 
change, and is therefore best administered in the form of a powder, given 
from one to three hours before the allotted time of sleep, in hot milk, or, 
if this be not obtainable, in hot water. Chloral still remains the most 
efficient of the hypnotics. It must be given in solution, well diluted, and, 



FUNCTIONAL NERVOUS DISEASES. 



463 



as it acts immediately, not until the subject is in bed. Its use may be 
continued for a length of time. Poisoning by it differs from that by sul- 
phonal in that the symptoms come on gradually and abate upon the 
withdrawal of the drug. Chloralamide acts very much as does chloral, 
but is more uncertain. Trional is a useful hypnotic, fairly active and 
certain in its influences, and in many cases efficient without producing 
unpleasant symptoms. When continuously pushed it sometimes seems to 
cause general weakness. The relative doses of these narcotics may be 
considered to be : hyoscine, one one-hundred-and-twentieth of a grain ; 
sulphonal, fifteen grains ; chloral, ten grains ; chloralamide, fifteen grains ; 
trional, twelve grains. In obstinate cases the best results are obtained 
by a combination of chloral with hyoscine or morphine : in obedience to 
the law of crossed action of drugs, by using such a combination the prac- 
titioner obtains a double effect where the two lines of drug-influence 
come together, which in the cases just mentioned is the cerebral cortex. 
Urethan is very uncertain in its action. Paraldehyde is so disagreeable 
and irritating to most stomachs that it usually cannot be borne, but in 
rare cases it acts kindly. 

Morbid Sleep. — Before discussing the more ordinary causes of morbid 
sleep it is necessary to speak of nelavan, African hypnosis or African sleep- 
ing disease, which is probably an acute fever, and is certainly often fatal. 
It is endemic on the west coast of Africa, but has occurred epidemically in 
the West India Islands. It attacks the negroes especially, but not solely. 
In most cases it comes on gradually, but it may begin brusquely. There 
is at first a slight frontal headache, with a sense of constriction in the 
forehead, attended by a mild fever. The vision may at this period be 
disordered. The gait becomes irregular, and not very infrequently there 
is a distinct ataxia. Even during the first hours of the headache an 
intense desire for sleep is manifested. The strength fails, the spirits are 
depressed, and there is some fever, but usually neither diarrhoea nor con- 
stipation develops, and the forces of the circulation are well maintained. 
Sleepiness in a short time deepens into a somnolence which becomes more 
and more intense and ends in a profound coma, which may pass quietly 
into death. Violent convulsions and sloughing bed-sores are liable to 
develop. There is no pathognomonic post-mortem lesion, unless it be 
swelling of the glands, and there is no known specific treatment. 

Omitting toxsemic somnolence, most of the cases of morbid sleep seem 
to be referable to one of five groups : 

Group 1. Sleep due to reflex irritations. 

Group 2. Narcolepsy, or idiopathic sleep of unknown cause. 

Group 3. Hysterical and epileptic sleep. 

Group 4. Sleep of insanity. 

Group 5. Somnolence connected with organic brain -disease. 
Of the third, fourth, and fifth of these groups sufficient has already 
been said. Keflex sleep is very rare, but Katerbau has recorded a case in 



464 



DISEASES OF THE NERVOUS SYSTEM. 



which a seventeen-year-old Jewess, who had slept four days and nights, 
immediately awoke after the passage from the rectum of a knot containing 
twenty-four round worms, whilst Mayer has related a similar case of a boy 
nine years old. 

Under narcolepsy are grouped cases of morbid sleep, probably repre- 
senting different affections, whose causation and nature are so obscure 
that at present no explanation of them can be offered. The best that can 
be done is to separate the cases into three subgroups, which are, however, 
connected by intermediate cases. 

In the first of these groups belong instances of perpetual drowsiness, 
in which the subject habitually falls asleep at the slightest provocation, 
and whenever awake is sleepy, or in which there come daily paroxysms 
of overpowering drowsiness relieved by a long nap. It is, perhaps, justi- 
fiable to consider these cases as instances of excessive development of the 
normal sleep function of the brain. 

In the second class of cases the normal relations between sleep and 
wakefulness are so altered that the two conditions, instead of alternating 
every twenty-four hours, alternate at long intervals. Thus, in the re- 
corded case of a Jewess, the average length of the sleeping and waking 
periods was five and a half days, the maximum was seven days, and 
the intervals of wakefulness were broken only by short restless bits 
of slumber. 

The third class of cases is that in which the sleep comes on without 
apparent cause and becomes more and more profound until the patient 
dies. Such a paroxysm suggests brain -congestion, and some cases have 
yielded to a very free venesection. That, however, fatal sleep without 
determinate cause may occur is shown by the case reported by Dr. S. 
Weir Mitchell, in which, after a prolonged seemingly causeless sleep 
ending in death, a most careful post-mortem examination failed to detect 
any lesion. 

Accidents of Sleep. — Sense-shock is an aura-like sensation, rising 
from the feet or hands at the moment of waking, and passing upward to 
the head, where it disappears in the sense of a blow or shock, or of a 
bursting, with in some cases a subjective special-sense disturbance, such 
as a loud noise, a strong odor, a vivid flash of light. Such paroxysms 
may also occur during the daytime ; they have no serious significance, 
and require no farther treatment than the upbuilding of the strength 
of the patient. 

MgM palsy is a sense of numbness in one or more extremities of the 
body, usually felt on waking, but occasionally occurring in the daytime. 
It may be monoplegic, hemiplegic, or general over the whole body. S. 
Weir Mitchell speaks of it as preceding locomotor ataxia, but it is very 
common in hysterical women about the climacteric, and also occurs in 
gouty subjects. It has no special significance, and is certainly not indica- 
tive of failure of circulation or of organic nervous disease. 



FUNCTIONAL NERVOUS DISEASES. 



465 



Somnambulism is a condition in which a dream so takes possession of 
the sleeper that he rises, walks, and acts. Movements and muttered words 
are very common evidences of dreaming in a sleeper, and every grade be- 
tween the slightest dream-movements and the most active sleep-walking 
exists. If the somnambulist be approached, his eyes will be found to be 
closed, or, if open, they, with the rest of the face, are impassive and 
without expression, paying no attention to the brightest lights, and 
appearing to have no power of sight in them ; yet obstacles are avoided, 
narrow places passed through, feats of balancing performed, and numer- 
ous complicated movements made so perfectly that the by-stander can 
hardly persuade himself that the sleeper is not awake. When seized, 
the somnambulist usually resists with vigor. Left to himself, after wan- 
dering for a greater or less length of time he returns to his bed, covers 
himself up, and sinks into the quiet forgetfulness of normal sleep. 

As it is often possible to direct a dream by answering the questions of 
the dreamer, so in somnambulism the thoughts of the sleeper can often 
be turned, and in obedience to a firm command he will return to bed 
without waking ; often, however, he is uncontrollable except by phys- 
ical force. Acts the most difficult and complicated, crimes of various 
character, and murder even, have been performed by the somnambulist 
in response to his dream impulses. 

The so-called night-terrors of childhood are a form of somnambulism, 
or are, in rare cases, epileptoid seizures. Nothing is more common than 
for a young child to go in the night to its parent's bed, trembling with 
terror or weeping bitterly, with the statement that it has had a bad 
dream. Such a dream may be so vivid as completely to enchain the 
attention, and if at the same time there be outward manifestations of 
the overpowering emotions from which the child is suffering, a paroxysm 
of night-terror results. Very frequently during the paroxysm the child 
shows terror of some one object, — a cat, a dog, an elephant, a mon- 
ster of some kind, as is indicated by its semi- coherent cries. In a large 
majority of cases night-terrors are of no more serious import than an 
attack of somnambulism. They often depend upon gastric irritation or 
too much emotional excitement during the day. In a few recorded cases 
the cause of the attacks has been intestinal worms. Those rare night- 
terrors which are due to serious disease can be distinguished only by 
their tendency to recur continually and by their concomitant symptoms. 
We have seen one case in which the night-terror in an adult, repeated 
at intervals during every night, was not affected by innumerable treat- 
ments instituted by various physicians of the highest class, and finally 
absolutely destroyed the usefulness of the subject's life. Again, we have 
seen the re-enaction of an escape from drowning recur night after night 
until it produced a most serious condition. In the treatment of night- 
terrors of children, especial care must be taken to remove intestinal 
worms, glandular swellings, or any other possible source of local irritation. 

30 



466 



DISEASES OF THE NERVOUS SYSTEM. 



Especially must the digestive system be put in complete order, and the use 
of stimulating foods and of caffeinic drinks positively forbidden. Any 
further general treatment of the night-terrors is that of neurasthenia and 
hysteria ; in the very acute sudden cases it may be necessary not only to 
put the patient fully under the influence of the bromides, but also to use 
narcotics at bedtime, so as at once to break up the habit, which if left to 
itself may become fixed and irremediable. 

CORRELATED DISORDERS OF MEMORY AND UNCONSCIOUSNESS. 

Every functional act in a nerve- cell is accompanied by nutritive change, 
and this nutritive change, although recovered from, leaves behind it 
a residue of effect. Hence all nerve- tissue has memory, — that is, the 
faculty of being permanently impressed by temporarily acting stimuli $ 
the thing remembered being, in fact, the functional excitement. In this 
is found the explanation of the results of training ; and in it, also, is 
found the explanation of the tendency of various functional nerve-diseases 
or conditions to perpetuate themselves after the removal of their original 
cause. It is in this way that, an accidental becomes a permanent epi- 
lepsy, that a physical habit becomes a habit- chorea. It is in this manner 
that the hysterical woman who gives way to an hysterical nervous im- 
pulse strengthens the hold of such impulse upon her nervous system 
until it may become irresistible. 

Moral habits are formed in obedience to the same law. Self-control, 
enforced at first by discipline, may become at last in the child an integral 
function of the nervous centre by a method parallel to that by which an 
accidental epilepsy is converted into a permanent disease. In the prog- 
nosis and treatment of disease, as well as in the training of the young, the 
full recognition of the power of habit— i.e., of unconscious memory — is a 
matter of vital importance. 

What is true of the lower nerve-centres and fibres is true of the upper 
ones. Intellectual acts or thoughts and perceptions tend to stamp them- 
selves upon the centres connected with them, and when the function of the 
nerve-cell is connected with consciousness the changes which occur in the 
nutrition give origin to conscious memory, — i.e., to memory in the usual 
sense of the term. 

These things being so, it must be that intellectual memory shall exist 
in as many varieties as there are intellectual actions. Disease sometimes 
dissects out, as it were, these different forms of memory. Thus, we have 
loss of word-memory, aphasia. In a case of dementia under our care, 
whilst memory for ordinary events was almost entirely lost, a joke or a 
ludicrous story would be remembered in all its details without effort. 
Again, the power of receiving new impressions is essentially different 
from that of preserving impressions which have been received ; and so 
in senile or other brain -degeneration it is very common for the power 
of remembering recent occurrences to be lost, although the recollection of 



FUNCTIONAL NERVOUS DISEASES. 



467 



events which happened in childhood days is more vivid than the normal 
condition of the individual would warrant. In examining, therefore, for 
the detection of failure of memory the physician should question the 
patient as to the simple happenings of the past twenty-four hours, and 
not be misled by the vividness of the recollections of the long past. The 
power of receiving impulses is usually lost before the power of recalling 
impulses. 

Exaltation of memory — that is, exaggeration of the power of receiving- 
new impulses or acquiring new thoughts — is very rare, but does occur in 
certain conditions of exalted function in the cerebral cortex, as in the 
insomnia of acute hyperemia or in the beginning of an acute perien- 
cephalitis. 

Memory and consciousness are so united that they are often confounded 
as one thing ; nevertheless they are distinct, and the link which binds 
them may be broken by disease. In this way arise certain cases of 
automatism, as that of the French soldier who, as the result of a wound 
in the head, was subject to attacks, lasting many hours, in which he 
gave no response to ordinary external stimuli and had no appearance 
of consciousness, but, if put in the position of marching or writing or 
smoking or what not, would go through the whole completed series of 
movements necessary for the performance of these acts, changing abruptly 
from one performance to another if taken hold of and put in a new 
position. 

The sense of personal identity is dependent upon the existence of memory 
and consciousness. The unbroken chain of events recorded from an in- 
definite past correlated with the consciousness of the present gives the 
realization of the unity of the present with the past. This sense of per- 
sonal identity is destroyed by a complete loss of memory, which loss may 
be abrupt and be unaccompanied by impairment of consciousness or of 
rationality. 

Double personality, the condition in which the subject feels as if he were 
two distinct personalities, the one alternating continually with the other, 
or more commonly the two coexisting, has no connection with loss of per- 
sonal identity nor yet with double consciousness. Its explanation is very 
difficult : it is occasionally seen as the result of hasheesh or other poison- 
ing, and also in insanity, in which affection it may become the basis of 
a delusion, as in the case of a patient of my own who was overwhelmed 
by the constant doubt whether he was himself or his own double. 

Double consciousness, so called,— periodical failure of memory, or periodic 
amnesia, — is a disorder of memory which also involves all the intellectual 
functions and the character of the individual. In a typical case there is, 
first, an abrupt loss of memory at the beginning of each paroxysm for 
everything that has happened during paroxysms not of the same series ; 
second, a change in the personal character of the individual, the disposi- 
tion, the habits of thought, and even the intellect vial powers, being altered. 



468 



DISEASES OF THE NERVOUS SYSTEM. 



After a time the subject goes abruptly back to the first condition, and so 
leads a double life of alternating states. 

Double consciousness is allied to epileptic automatism, which indeed 
may be considered a form of double consciousness, and also to certain 
conditions of insanity, in which the attacks come and go without apparent 
reason. 

NEURALGIA. 

Definition. — A violent pain following the course of a nerve-trunk 
and connected with no known disease, and for which we can give no 
adequate explanation. 

Etiology. — Owing to the curious feeling of " knowing all about it" 
which the average human individual derives from a name, in practical 
life it is often necessary to have a name which shall answer as a cloak 
for professional ignorance. The word " neuralgia" means a nerve-pain, 
which is in fact no meaning, as all pains are nerve-pains; but almost 
from time immemorial the term has been used to signify a class of cases in 
which violent pains occur in nerve- distribution from causes which cannot 
be made out. As knowledge has increased there has been a great reduc- 
tion in the number of cases of neuralgia ; because most of the cases which 
were formerly said to be instances of neuralgia now are known to be 
examples of neuritis, organic disease of the nerve-centres, etc. 

A form of pain which is still often spoken of as neuralgia is the reflex 
pain, in which the sensation is due to some distant irritation ; as examples 
may be cited the violent pain in the angle of the jaw occasionally pro- 
duced by eating very cold ice-cream or by other gastric irritation. Anstie 
has described various cases of what he termed neuralgia in the urethra and 
testicles, due to the irritation of self-abuse. A trigeminal pain may be due 
to a neuritis propagated from a diseased tooth-pulp, or it may be reflex, as 
is proved by its occurring in the side of the head opposite the affected 
tooth. Impacted faeces, and fissure of the anus, frequently produce so- 
called intestinal neuralgia and cystic neuralgia. We have seen as the 
chief symptom produced by a tape- worm a mastoid pain so violent as to 
lead to the diagnosis of disease of the bone and to operation. Ferrier 
has recorded instances of cervico-brachial neuralgia resulting from a dis- 
eased tooth. The pain of hepatic irritation is very commonly referred to 
the shoulder, and we have seen as the chief symptom of gastric perfora- 
tion, with escape of a meal into the abdomen, a mortal agony referred to 
the root of the neck. Reflex pains should never be spoken of as neural- 
gias, but as reflex pains. Their relief depends upon the acuteness of 
the medical attendant in discovering the cause of the irritation and his 
success in removing it. 

Neuralgias are frequently spoken of as being produced by lead and 
other poisons. Such neuralgias are in great part, probably always, in- 
stances of neuritis. In a very large proportion of the cases which are still 
diagnosed by practitioners as neuralgic, gouty disorder of metabolism is 



FUNCTIONAL NERVOUS DISEASES. 



469 



the cause of the suffering. Functional pains, or rather pains from dis- 
ordered functions, without organic lesions in the nerves or elsewhere, 
may be the result of anaemia or of a peculiar exhaustion. To such cases 
the term neuralgia may be well applied. 

There is, however, a final group of cases in which neither during life 
nor after death are we able to detect any cause for the pain. It would seem 
that there may be a molecular change either in the sensory nerve-centres 
or in the nerves themselves so fine as to escape our instruments, which 
predisposes the individual to suffer, so that a change of weather or other 
untoward influence too slight to be felt by the normal man causes a pain- 
storm. There appears to be a distinct general condition which may be 
known as the neuralgic temperament or diathesis. This is often inher- 
ited, but may be developed by prolonged bodily exhaustion or other causes. 
When once acquired it may persist although the original cause has been 
removed. The pains which come to some persons in malarial anaemia 
probably are often neuralgic, but when the anaemia has been relieved, if 
the nervous system has been sufficiently long impressed, the pain-tendency 
becomes stamped upon it, precisely as the epileptic tendency becomes con- 
stitutional in a case of reflex epilepsy and persists after the removal of the 
original irritation. These neuralgic pains are to be recognized by their 
persistency, by the absence of cause, and by the excluding of all other 
sources of pain. The acquired or inherited neuralgic temperament is 
closely connected with the migraine heredity, as well as with inherited 
gout ; but exactly what the relations between the three conditions are is 
still obscure. The neuralgic diathesis corresponds with the general neu- 
rotic temperament, is more frequent in women than in men, and is often 
prevalent in dry neurotic climates and in persons free from gouty symp- 
toms. The neuralgic temperament is further allied to hysteria and to 
neurasthenia, and especially to the neurasthenia which follows severe 
traumatisms. The nervous headaches spoken of elsewhere (see page 457) 
should perhaps be classed as neuralgic. 

Diagnosis. — The diagnosis of neuralgia is to be reached chiefly by ex- 
clusion. When no proper cause can be found for a pain in a nerve-trunk, 
such pain may be spoken of as a neuralgia. A great majority of cases of so- 
called neuralgia are really instances of gouty neuritis. Diseases of nerve- 
centres produce pains which in their character are indistinguishable fi-om 
true neuralgia except by their greater severity and persistency. When- 
ever a neuralgia is persistent in a definite nerve territory a centric lesion 
should be suspected, unless there be a gouty diathesis. The pains of pos- 
terior spinal sclerosis may closely simulate neuralgia, and if they precede 
the development of the more characteristic symptoms may lead to mis- 
taken diagnosis. The occurrence of persistent neuralgic pains in the legs, 
associated with a single symptom of a spinal sclerosis, such as Argyll- 
Robertson pupil or loss of the knee-jerk, will afford sufficient ground for 
a probable diagnosis of the centric disorder. 



470 



DISEASES OF THE NERVOUS SYSTEM. 



In the diagnosis of obscure cases of nerve-pain the greatest care should 
be exercised in searching for a possible distant point of irritation which 
may produce reflex pain. 

Treatment. — The treatment of nerve-pain depending upon gout, 
malaria, organic nerve-disease, etc., is essentially the treatment of the 
underlying condition. The treatment of ordinary neuralgia, so called, is 
usually that of a rheumatic neuritis. The treatment of a true neuralgia 
must have for its basis also the relief of the underlying bodily state. 
Commonly there is vital depression, often with lowered nutrition, some- 
times with anaemia. This state must be met. Thus, if there be failure 
in the development of fat, cod-liver oil may be of great service ; if there 
be anaemia, iron may be employed, etc. Always, however, great care 
should be taken not to interfere with digestion by drugs. 

In true neuralgia electricity is of no value. Over a neuralgic nerve- 
storm, such as migraine, or the paroxysms of pain which are said some- 
times to replace epilepsy, electricity has no power. In the pain of a 
neuritis it often brings relief. Local anodynes and mild counter-irrita- 
tions are sometimes of service in neuralgia. Antipyrin, phenacetin, and 
other allied coal-tar products will very often control the pain. Whenever 
it is possible, complete change of scene, with out-door life, should be 
tried if other measures have failed. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 471 



CHAPTER III. 

ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 
CEREBRAL LOCALIZATION. 

The term cerebral localization is used as a name for the applied 
science which has grown out of the recognition of the fact that, in the 
processes of functional evolution and differentiation in the animal king- 
dom, the human brain has become so specialized that certain functions 
have been permanently assigned to certain portions of it, so that it is 
possible to recognize the anatomical seat of a lesion by noting the dis- 
turbances of function. In applying our knowledge for the purposes of 
diagnosis it is essential to remember that it is the seat and not the nature 
of the lesion which it is the purpose of cerebral localization to discover. 
A tumor in a certain spot in the brain produces the same disablement 
whether it be cancerous, tubercular, or of other nature. We can only note 
that purely destructive lesions paralyze function ; that irritative lesions 
at the same time excite and pervert function ; and that many lesions are 
both destructive and irritative. Thus, a destructive lesion of the portion 
of the brain connected with vision causes blindness, an irritative lesion 
causes active disturbance of vision, such as flashes of light : again, a de- 
structive lesion of the motor region of the brain causes paralysis, an 
irritative lesion causes spasm ; whilst a lesion which is both destructive 
and irritative causes paralysis with spasm which is apt to take the per- 
manent form known as contractures. It may be further noted that the 
symptoms of irritation are more apt to be produced when the lesion 
affects the nerve-centres themselves than when the conducting fibres 
from those centres are attacked. 

We have no definite information as to the seat in the human brain of 
consciousness and the intellectual faculties, or whether, indeed, these func- 
tions are confined to certain limited regions or are generalized through- 
out the whole brain-structure. It is commonly supposed that the frontal 
lobes of the brain have some especial relation to these functions, but cer- 
tain it is that a gross lesion of an anterior lobe may exist without regis- 
tering itself by any characteristic symptom. The function of motion is 
situated in the region of the cerebral cortex lying about the Eolandic 
fissure, whilst that pertaining to the special senses is situated in the 
occipital, temporal, and olfactory lobes: so that we may naturally divide 
the brain- cortex into the silent, the motor, and the sensory area, as in 
the diagram on the following page. 

In the diagram no notice of speech- centres is taken, because human 
speech is so complicated in its physiology and so widely distributed in 



472 



DISEASES OF THE NERVOUS SYSTEM. 



the anatomical location of its centres that it demands the elaborate dis- 
cussion given at the close of this article under the head of Aphasia. 



Fig. 3. 




External lateral view of brain, showing general arrangement of cerebral centres. 



Active nerve-centres always have efferent nerve-fibres forming paths 
along which run the impulses originating in the ganglionic nerve- cells ; 
from which it follows that in discussing the localization of a brain-func- 



Fig. 4. Fig. 5. 




Lateral view of inner surface of hemisphere. tions of the nomenclature used in the text. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 



473 



tion it is first in order to speak of the centres implicated, and then of 
the nerve- fibres. 

Fig. 6. 

Fissure Roland! 




Diagram showing cerebral convolutions. The anterior central convolution and the posterior central 
convolution are respectively the ascending frontal and the ascending parietal convolution of the text. 

MOTION. 

The motor, or, as it is better termed, the psycho -motor area of the 
brain is the part where thought originates the impulses which finally 
end in muscular contraction. It comprises the ascending frontal and 
parietal convolutions, including the upper portion, which is seen on the 
median surface of the cerebrum, and constitutes the so-called paracentral 
lobule. The gross arrangement of the centres is shown in the diagram 
(Fig. 3). It must be understood that these centres are not sharply de- 
fined from one another, but overlap. The highest part of the region 
is occupied by the leg- centres, which certainly also reach into the para- 
central lobule. The arm- centres, which occupy the middle third of these 
convolutions, probably extend higher in the ascending frontal than in 
the ascending parietal. The lower third of the ascending frontal con- 
volution is the chief centre for the face movement, but there is reason 
for believing that the corresponding part of the ascending parietal con- 
volution is also involved. The centre of the movements of the angles 
of the mouth lies at the upper junction of the lower ends of the two 
convolutions, or, in other words, just below the lower end of the fissure 
of Eolando ; whilst the lips and tongue receive their innervation from 
the foot of the ascending frontal convolution, the centres probably also 
extending into the third frontal convolution. 

Horsley and Schafer have found that in the monkey the posterior half 
of the upper and lower frontal convolutions and the inner aspect of the 
summit of the ascending frontal convolution (a portion of the paracentral 
lobule) are respectively connected with the lateral movements of the 
head and eyes and with the movements of the trunk or body ; and it is 



474 DISEASES OF THE NERVOUS SYSTEM. 

probable that in man this connection holds. There is reason for be- 
lieving (see Hemiplegia) that in muscles which absolutely work to- 
gether so closely as those of the trunk each muscle receives innervation 
from each side of the brain, a theory which is borne out by the fact that 
destruction of one of these centres fails to produce permanent paralysis. 

The motor fibres* which arise from the psycho-motor area of the brain 
are at first widely separated, but converge as they pass inward through 
the centrum ovale, and when they reach the internal capsule are con- 
densed into a very narrow territory. The pathway to the inner capsule 
is double, one mass of fibres passing between the caudate and the len- 
ticular nuclei, and the other between the lenticular nuclei and the optic 
thalamus. In the passage of these fibres the course of their direction is 
changed from vertical to horizontal. The fibres connected with the face 
are originally the lowest in the cortex, so that their pathway through the 
centrum ovale lies below that of the fibres connected with the extremi- 
ties. In the change of their course from the vertical to the horizontal 
direction, however, they get in front, so that their pathway is through 
the bend or angle of the internal capsule. 

In the internal capsule the fibres from the facial centres are thus 
placed anteriorly near the so-called knee ; next to them come the fibres 

from the arm-centres ; then the leg- 
fibres, the boundaries between the 
bands not being sharply defined. 
Together these motor tracts form 
about two-thirds of the posterior limb 
of the internal capsule, the hinder 
third of the limb being occupied by 
the sensory pathway. From the in- 
ternal capsule the motor fibres pass 
into the eras cerebri, where they oc- 
cupy the middle two-fifths of the 
crusta, extending from the surface 
below almost to the substantia nigra. 

In the eras cerebri the facial 
nerves begin to leave the main body 
of fibres, the oculo-motor nerve 
emerging from the inner surface of 
the crura. Most of the fibres, however, of the cranial nerves enter the 
pons, but very shortly after so doing they separate from the band of fibres 
which go to the body and extremities, and cross over to the opposite 
side of the pons to enter their various nuclei. The main portion of the 
motor fibres enters the pons and passes through the crustal portion lying 



* The idea of the construction of the brain and spinal cord in their motor func- 
tions is— ganglion-cells in the cerebral cortex, which originate an impulse that passes 



Fig. 7. 




Transverse horizontal section of brain, showing 
internal capsule and its relations. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 475 

between the superficial and deep layers of the transverse fibres and sur- 
rounded by gray matter, with which, however, they have no connection. 
In this passage through the pons the mass of fibres is broken up into 
bundles, which a little lower down are again gathered into one string, as 
which they enter the medulla. In the medulla this string divides, the 
greater part of it passing over to the opposite side to be continued down 
jthe spinal cord as the lateral or crossed pyramidal tract, whilst the 
smaller portion, failing to decussate, enters the spinal cord upon the 
side corresponding to that of the cerebral hemisphere in which it origi- 
nated, to constitute the anterior or direct pyramidal tract. During their 
passage from the cerebral cortical centres to the spinal cord these white or 
conducting nerve-fibres are distinct, and apparently without connection 
with ganglionic cells. 

In the neighborhood of the internal capsule are the great cerebral 
ganglia, namely, the optic thalamus and the caudate and lenticular 
nuclei (corpus striatum). The function of these centres is unknown, the 
old view that they were connected with the motor fibres going from the 
cortex having apparently been disproved. The thalamus has close con- 
nection with the optic tract and also with the cerebral cortex. The corpus 
striatum appears to have special functional relations with the cerebellum, 
with which it has anatomical connections, and by whose development it 
is influenced, since failure in the development of the cerebellum is always 
accompanied by a great reduction in the size of the corpus striatum. 

In studying the sensory brain-functions the first natural division is 
that of General Sensation, including the touch, thermic, muscular, and 
pain senses, and the so-called Special Senses. 

SENSATION. 

General Sensibility. — We have no knowledge whatever of the localiza- 
tion of the different forms of so-called general sensibility 5 indeed, the 
position of the cortical centres which preside over the sense of touch 
itself has not yet been definitely determined. The only fixed anatomico- 
physiological point that we have is that the fibres which convey sensory 
impulses to the perceptive centres in the brain- cortex pass through the 
posterior third of the internal capsule. According to Flechsig, these 
fibres pass upward from the capsule towards the cortex through the 
region which lies beneath the parietal bone, — that is, to the region of the 
psycho-motor convolutions and the parietal lobe. As the result of ex- 



down nerve-fibres and exerts an influence upon cells in the spinal ganglia that causes 
them to discharge force, which in turn produces contraction of the muscles. It will 
be seen, therefore, that physiologically the spinal system must be considered to com- 
mence in the crus cerebri, for here is the first pair of ganglia (that of the oculo- 
motor nerve) which have the power of directly causing muscular movement. The 
spinal system is then continued through the pons, where certain of the nerves of the 
head have their nuclei, and through the medulla into the cord itself. 



476 



DISEASES OF THE NERVOUS SYSTEM. 



periments upon monkeys, Horsley and Schafer, however, locate the cen- 
tres for painful and tactile sensations in the gyrus fornicatus ; Ferrier 
found them in the gyrus hippocampi. Apparently, therefore, the sense 
of sensation is located in the whole of the falciform lobe. Cases con- 
firming this have been reported by Thomas Savill, who thinks that the 
posterior part of the gyrus fornicatus is the cerebral centre for tactile 
sensation in the arm ; nevertheless, the view of Flechsig seems to be 
better borne out by the scanty pathological data which have been ac- 
cumulated, as in various cases lesions of the parietal region have pro- 
duced hemianesthesia, whilst not rarely in legs or arms paralyzed by 
lesions in the psycho-motor cortex there is blunting of sensibility. The 
large collection of cases made by Dana indicates that it is especially the 
posterior half of the psycho-motor area that is concerned with sensation.* 

The course of the sensory fibres below the inner capsule is still a 
matter of much doubt. It is known, however, that in the peduncles the 
fibres pass through the so-called tegmentum, i.e., through the posterior 
or superior portions of the crus, separated more or less distinctly from 
the crusta or motor pathways by the ganglionic mass known as the locus 
niger, and then continue through the pons without decussation until 
they reach the spinal cord. 

Searing. — The cortical centre for the perception of auditory impulse 
appears to be in the posterior half of the first temporal convolution*. 
The loss of hearing due to the destruction of this convolution has, 
however, been found, both in the lower animals and in man, not to be 
permanent. There is some reason for suspecting that the cortical audi- 
tory centres may be of wider range than that spoken of, and that out- 
lying portions of these centres may take on superactivity when the cen- 
tral parts are destroyed ; but it is more probable that each auditory nerve 
is connected with both hemispheres, although only the connection with 
the opposite hemisphere is habitually functionally active, and that there- 
fore it is possible for the opposite convolution to assume the function of 
the destroyed portion. We have no knowledge of the pathway between 
the cortical auditory centres and the auditory nucleus in the medulla 
oblongata, except that this pathway passes through the posterior portion 
of the internal capsule. The auditory nerve is so exposed that in the 
great majority of cases nervous deafness is peripheral. 

Smell. — There are indications from experiment and also from pathol- 
ogy that the centres of smell are in the front portion of the uncinate 
convolution, to which fibres from the olfactory nerve have been traced ; 
but the subject is still involved in great obscurity. 

Taste. — The sense of taste is so much affected by catarrh and other 

* Disturbances of sensibility are very commonly hysterical. Charcot was inclined 
to believe that loss of muscular sense is always so ; but Ransom reported a case in 
which it followed a traumatism and was relieved by trephining, and Carter Gray 
one in which it was caused by a sarcomatous tumor in the parietal convolutions. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 477 

abnormal conditions of the mucous membranes of the mouth that care is 
sometimes necessary to avoid being led into mistakes of interpretation. 
Loss of taste, or ageusia, may be due to disease of the glosso-pharyngeal 
nerve, in which case it is confined to the side of the tongue supplied by 
the affected nerve. In a number of cases it has been produced by dis- 
ease of the trigeminal nerve, but in other cases it is alleged that taste 
has been normal though this nerve was very markedly affected. Again, 
the extreme tip of the tongue seems to depend upon branches of the 
chorda tympani for the taste-function ; hence disease involving the 
chorda tympani affects taste. 

Loss of taste may be part of a general hemiansesthesia, so that it is 
probable that the fibres passing from the cortical receptive centres of 
taste run through the posterior part of the internal capsule ; as to their 
further course we have no knowledge. There is much doubt as to the 
situation of the receptive centres in the cortex, but cases have been re- 
corded in which tumors occupying the hippocampal region have ap- 
parently affected the sense of taste. 

In testing any case for a loss of taste, three regions, the front of the 
tongue, the back of the tongue, and the palate, should be separately 
examined. The patient should be blindfolded, and quinine or salicin, 
diluted vinegar or lemon-juice and salt, or other highly sapid matter, 
employed. In order to prevent confusing smell with taste, the testing 
substances should be free from marked odor. 

Parageusia, perversion of taste, and hypergeusia, excessive sensitiveness 
of taste, are usually of hysterical or psychical origin. 

The relations of the eye to the detection of cerebral disease are very 
complicated : they pertain to the optic disk, to the pupil, and to the 
function of vision. 

Optic Disk. — It is customary among ophthalmologists, following Von 
Graefe, to make three alterations of the optic disk connected with disease 
of the nervous system : the first of these is atrophy, which occurs in 
various sclerotic diseases of the brain and the spinal cord, or as a sec- 
ondary result of choked disk ; the second is the so-called choked disk ; 
the third is descending neuritis. In choked dish there is a projection of 
the end of the nerve, which is oedematous and opaque, with its margins 
obliterated and its vessels swollen. In descending neuritis the disk is 
described as less swollen and more red, with tortuous veins and arteries. 
Practically, choked disk and descending neuritis may be looked upon as 
one thing, both having similar significance and each ending in atrophy. 

The most probable explanation of choked disk is that it is the result 
of an excessive pressure upon all the lymphatic spaces of the brain, 
which manifests itself especially in the lymphatics of the optic disk, 
which are on the surface of a chamber and therefore lack the support 
of contiguous tissues. Theoretically, choked disk is dependent upon 



478 



DISEASES OF THE NERVOUS SYSTEM. 



Fig. 8. 



brain-tumor, abscess, meningitis, or other gross lesion which increases 
cerebral pressure, whilst descending neuritis is the outcome of a basilar 
meningitis. Practically, however, there is no difference in the signifi- 
cance of the two conditions. 

A choked disk may be unilateral, in which case it is usually due to 
local disease, but may be rheumatic. In rare cases either of the affec- 
tions under consideration may be the outcome of other causes than brain- 
tumor or inflammation ; the more rapid the development of increased 
intra-cranial pressure the more positive the ocular manifestation ; but 
when the increase of pressure is slowly developed the choked disk may be 
absent. It is wanting in about fifteen per cent, of cases of cerebral tumors. 

Pupils. — Myosis and mydriasis are not localizing symptoms; in- 
equality of the pupil may or may not be a localizing symptom. The 
pupil is subject to three forms of movements: first, that produced by 
light ; second, the so-called cutaneous pupillary reflex, by virtue of which 
pinching the skin causes dilatation of the pupil; third, the changes 
which accompany accommodation. The Argyll- Eobertson pupil is a 
condition in which no movement of the pupil is produced by pinching 

the skin or by throwing a bright light 
into the eye, although the relations 
between the pupil and the accommo- 
dation are preserved, dilatation of the 
pupil occurring when vision is sud- 
denly taken from a near to a distant 
object. 

In the Argyll-Eobertson pupil, 
which occurs chiefly in spinal sclero- 
sis, the failure of the pupil to con- 
tract under the stimulus of light shows 
that there is a lesion in the arc 
UGBF, or, in other words, that either 
the optic nerve or its centre, or the 
•if connection between the optic centre 
and the oculo-motor centre, or the 
oculo-motor centre or its nerve, is 
diseased. The retention of normal 
vision shows that the optic nerve 
and its nucleus are perfect ; the occur- 
rence of movements during the process 
of accommodation proves that the 
oculo motor nerve and its centre are 
active : the interruption in the arc ECBF must therefore be between the 
optic and the oculo motor centre, or, in other words, in the commissural 
fibres which connect the optic and the oculo-motor centre. The loss of 
the cutaneous pupillary reflex proves that there is some interruption in 




A, nerve-fibres from the cerebrum ; B, optic 
centre ; S, optic nerve ; E, pupil ; F, retina ; H, 
oculo-motor nerve ; C, oculo-motor centre ; D, 
ocular centres in the cervical spinal cord fcilio- 
spinal axis of Budge) ; IK and IL, sympathetic 
nerves ; M, N, and O, sensory nerves. (After Erb.) 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 479 

the arc MDL, this interruption probably being in the spinal cord and 
due to the lesion which interrupts the continuity of the pathway between 
the oculo-motor and the optic centre. 

Vision. — Amaurosis, or blindness, amblyopia, or partial blindness, 
hemianopsia, or seeing one-half of the field of vision, scotomata, or blind 
spots in the field of vision, and contraction of the field of vision, are the 
chief forms of visual deficiency. In studying the relation of these to 
cerebral localization it is necessary first to recognize that the visual 
nerve apparatus consists of perceptive centres situated in the cuneus 
(occipital lobe), and of conducting fibres which pass from these centres 
beneath the angular gyrus and through the posterior portion of the in- 
ternal capsule down to the geniculate bodies and the superior quadri- 
geminal bodies, whence a flattened band of fibres goes across the upper 
anterior surface of the cerebral peduncle to the optic chiasm, which is 
situated upon the olivary eminence of the sphenoid. In the chiasm each 
nerve divides into two bands, of which the larger or outer band decus- 
sates with its fellow, or, in other words, crosses over to enter the optic 
nerve as it emerges from the opposite side of the chiasm and to be finally 
distributed to the nasal half of the retina. The inner or smaller band of 
fibres passes on through to the chiasm, without decussation, to the outer 
side of the retina of its own eye. 

The diagram on page 480 shows diagrammatically the visual paths 
from the perceptive centres to the retina. It will be seen that each 
cuneus is connected with the half of each retina corresponding to itself 
in position, — the left cuneus with the left half of each retina, the right 
cuneus with the right half. Paralysis of one cuneus, therefore, must pro- 
duce paralysis of the corresponding half of each retina, the so-called 
homonymous hemianopsia, or homonymous lateral hemianopsia. Paralysis of 
a portion of a cuneus would produce hemianopic scotomata. 

Interference with the functions of one optic tract at any position be- 
tween the cuneus and the commissure will produce the same symptom as 
does disease of the cuneus, homonymous lateral hemianopsia. A lesion 
of the optic chiasm will produce disturbances of vision varying according 
to its situation. If it press backward from the front of the chiasm 
(T.6, Fig. 9) it may produce hemianopsia of the opposite halves of the 
eyes, heteronymous hemianopsia. If it be placed laterally (T.3, Fig. 9) 
it may produce great inequality of vision of the two eyes. Homony- 
mous hemianopsia is spoken of as temporal when both temporal fields 
are involved ; as nasal when both nasal fields are affected. A paralysis 
of one optic nerve in front of the chiasm will produce amaurosis, or, if 
not complete, amblyopia, of the eye of the same side. 

Horizontal hemianopsia, in which the vision is paralyzed in the upper 
or lower half of the eye, is almost always due to disease of the eye itself, 
but has been produced by a tumor pressing from above downward upon 
the optic chiasm. 



480 



DISEASES OF THE KEEYOUS SYSTEM. 



Contractions of the field of vision, if not hysterical, are usually due to 
diseases of the optic nerve. They are not rare in locomotor ataxia and 
other forms of spinal sclerosis, in which atrophy of. the optic nerve-fibres 
is very apt to occur, and they also accompany optic neuritis. 



Fig. 9. 




Diagram of visual paths, designed to illustrate specially left lateral hemianopsia from any lesion : 
L.T.F., left temporal half-field; R.N.F., right nasal half-field; O.S., oculus sin. ; O.D., oculus dexter; 
N.T., nasal and temporal halves of retinae; N.O.S., nervus opticus sin. ; N.O.D., nervus opticus dext. ; 
F.C.S., fasciculus cruciatus sin. ; F.L.D., fasciculus lateralis dext. ; C, chiasma, or decussation of fasciculi 
cruciati; T.O.D., tractus opticus dext. ; C.G.L., corpus geniculatum laterale : L.O., lobi optici (corpus 
quad.); P.O.C., primary optic centres, including lobus opticus, corp. genie, lat., and pulvinar of one 
side; F.O., fasciculus opticus (Gratiolet) in the internal capsule ; CP., cornu posterior; G.A., region of 
gyrus angularis; L.O.S., lobus occip. sin. ; L.O.D., lobus occip. dext. ; Cu., cuneus and subjacent gyri 
constituting the cortical visual centre in man. The heavy or shaded lines represent parts connected with the 
right halves of both retinse. 

Scotomata may occupy any part of the visual field, and be due to 
disease of the retina. They may be the outcome of a very small cuneal 
lesion. When symmetrical and central they are in most cases the result 
of tobacco poisoning.* 

* In tobacco poisoning the loss of vision is never complete. It is especially 
marked for the perception of colors, for green and red in particular ; the former is 
usually described by the patient as "white" or "gray," and the latter as "brown" 
or "no color at all." In most cases the scotoma is smaller than the visual field for 
central colors, green and red, and hence a zone is present beyond the scotoma in 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 



481 



Diplopia is in the vast majority of cases binocular, and due to a paralysis 
or spasm of the eye-muscles, which disturbs the coordination of the eyes 
and throws their axes out of their normal parallelism. It may be crossed 
or simple. Crossed diplopia occurs in cases of divergent squint ; the image 
seen by the left eye lies to the right of that seen by the right eye. Simple 
or homonymous diplopia exists in convergent squint. In it the image seen 
by the left eye lies to the left of the other image. A great aid to the 
memory in regard to diplopia is afforded by remembering the rule laid 
down by Gowers in his lectures, — namely, that when the prolonged axes 
of the eyes would cross, the images are not crossed ; whilst when the 
prolonged axes would not cross, the images are crossed. In other words, 
convergent squint causes simple diplopia, divergent squint causes crossed 
diplopia. 

Monocular diplopia — i.e., the seeing with one eye of one object as two 
— is a very extraordinary symptom, which may be present in one or both 
eyes. It has been noted as the result of protracted use of the eye with 
the microscope ; as due to defects in the eye itself, relieved by spectacles ; 
and as the outcome of cerebral traumatism and of various organic lesions. 
There appear to be three classes of cases : first, those in which the lesion 
is of that portion of the eye which transmits light ; second, those in which 
there are troubles of refraction or accommodation ; third, those in which 
there is a cerebral lesion. According to our present knowledge, cerebral 
monocular diplopia has no localizing significance, as it has been reported 
in cases of tumors of the right ventricle, of softening of the convolutions 
of the right posterior hemisphere, of abscess of the temporo-sphenoidal 
and occipital lobes, and as the result of violent blows upon the head pro- 
ducing no demonstrable local change. Duret in one case of centric di- 
plopia found that the portion of the retina which perceived the double 
image was paretic. The best but not altogether satisfactory explanation 
of cerebral monocular diplopia as yet offered is that it is due to disasso- 
ciation of the two hemispheres, which results in each cuneus having a 
distinct conscious perception of its own image. 

Practical Locating of Lesions. — The following generalizations so 
evidently follow from what has already been said that they need no com- 
ment. First, destructive lesions of the ascending frontal or parietal 
convolution produce monoplegias of the face, arm, or leg, according to 
the part affected, or, if the lesions be sufficiently wide-spread, cause an 
association of monoplegias which may amount to a complete hemiplegia, 
with loss of sensibility by involvement of cortical sensory cells. Second, 
irritative lesions of the convolutions mentioned produce local convul- 
sions, spasms, or choreic movements in the part or parts corresponding 
to the centres. Third, destructive lesions in the centrum ovale, if large, 



which these colors are observed. This is especially the reason that the patient will 
recognize the color of a large body and mistake that of a very small one. 

31 



482 



DISEASES OF THE NERVOUS SYSTEM. 



Fig. 10. 



LEG 




cause hemiplegia, but if the lesion be minute a partially distributed hemi- 
plegia, — that is, a hemiplegia without involvement of the face or, it may 

be, of the leg, — whilst irritative lesions 
produce, usually, corresponding con- 
tractures. Either lesion may be ac- 
companied by a loss of sensibility upon 
the same side as the motor paralysis, 
due to division in the corona radiata 
of the fibres going to the sensory corti- 
cal centres. Fourth, a destructive lesion 
in the anterior two-thirds of the pos- 
terior limb of the internal capsule will 
produce a hemiplegia ; if, however, the 
lesion be very small and situated far 
anteriorly, the face will be most af- 
fected, the leg least so, and vice versa. 
Fifth, lesions in the middle third of the 
posterior limb of the internal capsule 
are prone to influence sensation as well 
as motion, on account of their tendency 
to encroach upon the posterior third of 
the capsule ; under these circumstances 
the hemianesthesia is upon the same 
side as the paralysis, because the lesion 
is above the decussation of both motor 
and sensory fibres. Sixth, if a lesion 
encroach upon the whole of the pos- 
terior third of the capsule the loss of 
sensibility is complete, affecting not 
only general sensibility, but also all 
the special senses, as at this point con- 
ducting fibres from each of the senses 
run together, constituting the so-called 
Seventh, permanent irritative lesions of 
the corona radiata or of the internal capsule may cause tremors or choreic 
movements (hemichorea, athetosis, post-paralytic chorea). Eighth, a de- 
structive lesion in the crus cerebri will produce a hemiplegia or a hemi- 
ansesthesia according as it is situated in the crusta or in the tegmentum, or 
it will produce a hemiplegia with a hemianesthesia on the same side if it 
encroach upon both regions ; if the lesion be so situated as to interfere with 
the oculo-motor nerve there will be an oculo-motor palsy opposite to the 
paralysis of motion and sensation. Ninth, a lesion in the pons situated 
high up may produce a hemiplegia or a hemianesthesia without involve- 
ment of the special senses, according as it is in the motor or in the sen- 
sory region, or it may produce a hemianesthesia and a hemiplegia upon 



Schematic diagram, after Van Gehuchten, 
showing motor pathway and paralytic effects 
of lesions. Ill, IV, V, VI, etc., on the right rep- 
resent nuclei of cranial nerves ; lesion at 1, 1', 
1", would cause respectively monoplegic paraly- 
sis of face, arm, or leg on opposite side ; lesion 
at 2 would cause complete hemiplegia of oppo- 
site side of body ; lesion at 3— if large enough 
to cut descending band of fibres and outgoing 
nerve— would cause opposite hemiplegia and 
oculo-motor paralysis on side of lesion (crossed 
paralysis) ; lesion at 4 would cause opposite 
palsy of arm and leg, with, if lesion were large 
enough, palsy of oculo-motor and facial nerve 
on side of lesion ; lesion at 5 would produce 
spinal paraplegia. 



" sensory crossway" of Charcot. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 483 

the same side. If, however, the lesion be not high up, — i.e., not above 
the decussation of the facial nerve, — it will cause an alternating paralysis 
in which the opposite sides of the face and body are affected ; or if it in- 
volve the sensory nerve-fibres it will produce hemianesthesia of the face 
upon the side opposite to the motor paralysis of the body, — the so-called 
alternating hemianesthesia. Tenth, destructive lesions of the optic thala- 
mus and of the striate body are apt to produce hemiplegia, probably by 
an influence upon the neighboring internal capsule. 

Lesion of the corpora quadrigeniina produces paralysis of the eye- 
muscles, with various anomalies of the pupils and lessening of the cen- 
tral vision (anterior pair), or of audition (posterior pair). According 
to Nothnagel, the union of double ophthalmoplegia with ataxia is char- 
acteristic of lesion of the corpora quadrigemina, but L. Bruns reports a 
case in which these symptoms were present in a tumor of the middle 
cerebellar lobe. It is probable that in cerebellar cases the ataxia always 
precedes, in quadrigeminal cases follows, the ophthalmoplegia. Tumors 
of the corpora quadrigemina are apt to produce an early and severe optic 
neuritis. 

ATHETOSIS. HEMICKOREA. 

Athetosis (see page 380) was described as a disease by Hammond, 
but is certainly only a symptom. In autopsies various lesions have been 
found ; in some instances they have been confined to the cortex, but in 
the great majority of cases the seat of the disease has been the internal 
capsule, or the parts in its immediate neighborhood. 

Under the name of double athetosis Michailowski described a disease 
characterized by peculiar involuntary movements over the whole body, 
but especially affecting the arms and legs and the two sides of the face, 
always associated with more or less rigidity of the limbs, and appearing 
almost always congenitally or in very early childhood in imbeciles, but 
sometimes developing in early adult life. 

As in simple athetosis, so in double athetosis various brain - lesions 
have been found ; there is, therefore, no constant nerve-lesion in double 
athetosis, so that the latter must be looked upon as a symptom, the out- 
come of various diseases of the brain which produce similar lesions in 
both hemispheres and consequently cause athetosis in each side of the 
body. Double athetosis is commonly associated with imbecility, because 
sclerotic and other brain diseases which produce athetosis are apt to 
destroy the mental faculties. 

Closely allied to athetosis are other forms of motor disturbance pro- 
duced by disease of the internal capsule or its neighboring parts. The 
most important of these are hemichorea, hemi-tremors, and especially the 
choreic movements which sometimes precede but more frequently follow 
cerebral apoplexies, constituting the so-called pre-hemiplegic and post- 
hemiplegic chorea. Charcot believed that the lesion of hemichorea was 
always in the posterior portion of the internal capsule ; hence the fre- 



484 



DISEASES OF THE NEETOUS SYSTEM. 



quent association of henrichorea with hemiansesthesia. It seems, how- 
ever, to be proved that any of these various disordered movements may 
be produced by lesions in the cortex or in almost any part of the motor 
tract ; indeed, Mengui asserts that they may result even from lesions 
of the spinal cord or of the peripheral nerves, and H. C. Wood's ex- 
periments upon choreic dogs certainly proved that both rhythmical and 
irregular choreic movements may be of spinal origin. 

APHASIA. 

Human beings communicate with one another by means of written and 
spoken words, by pictures or hieroglyphs, by signs, and by musical tones. 
For each form of communication there are necessary an apparatus for 
expression and one for the purpose of perceiving that which has been 
expressed by another person. Each apparatus is composed of two parts, 
one central, the other peripheral.* In the receptive apparatus are a 
peripheral receptive nerve-mass, a nerve-trunk, and a centre of con- 
scious perception. In the apparatus for expression is a brain- centre 
in which thought is converted into a word-impulse which, travelling 
outward, produces the motions which cause words, sounds, speech, ges- 
tures, etc. When the peripheral apparatus is paralyzed, communication 
is correspondingly interfered with, and there results loss of the power 
of articulation (anarthria), or loss of the power of perception, — that is, 
blindness and deafness. 

Cases in which the peripheral apparatus is alone at fault are not 
included under aphasia, this term being used to represent all forms of 
interference with human communication by disease of the higher nerve- 
centres immediately connected with conscious thought and its expression. 
It is plain that the interference may be with the function of emission or 
of reception, and there may be motor or ataxic aphasia, the loss of the 
power of expression, and sensory aphasia, the loss of the power of per- 
ception of that which has been expressed. 

Ataxic aphasia, as it may invade any form of expression, is divided 
into ataxic aphasia proper, or loss of the power of expression by spoken 
words ; agraphia, or loss of the power of expression by written words ; 
aglyphia, or loss of the power of picture-making ; ataxic amusia, or loss 
of the power of expression by musical tones (singing) ; musical agraphia, 
or loss of the power of writing music ; ataxic amimia, or loss of the power 
• of expression by gesture. 

Sensory aphasia is divided into word-deafness, or loss of power of 
recognizing heard words; word-blindness {alexia), or loss of power of 
recognizing seen, written, or printed words : figure -blindness, or loss of 
power of recognizing drawn or painted figures ; sensory amusia, or loss 



* Peripheral as here used includes the nerves and nerve-centres of the spinal 
cord or the medulla oblongata, or the special-sense ganglia at the base of the brain. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 485 



of power of recognizing heard musical tones ; sensory amimia, or loss of 
power of recognizing gestures. There have been cases in which the 
patient could sing the tune without words, and even intelligibly express 
desires by accents and intonations 5 others in which, with complete 
aphasia, agraphia, and word-blindness, the patient could sing the melody 
and also the words ; also, cases of word-blindness in which the patient 
could read musical notes, others in which he could recognize the word 
by tracing the letters with the finger. The language of emotions and the 
words in most frequent use are the longest preserved. Thus, aphasics can 
sometimes swear or pray, and "yes" and "no" are the last words to go. 

Any of the various forms of aphasia may be partial in its develop- 
ment. If its lack of completeness is general, it is often expressed by put- 
ting the prefix u par" before the name. Thus, partial loss of the power 
of recognizing musical notes is paramusia ; partial word- blindness, par- 
alexia. Medical literature also recognizes and has given name to various 
peculiar partial aphasias, which need only be mentioned here. Thus, in 
ataxic aphasia, when only the word or even a letter is concerned, the case 
is spoken of as one of monophasia, whilst the term paraphasia is used to 
express the condition in which the subject employs wrong words. IAteral 
agraphia is the condition in which the power of writing letters is lost ; 
verbal agraphia is that in which the power of writing words is alone 
affected; paragraphia is by some restricted to the condition in which 
wrong words are written. Sensory amusia is by Edgren known as tongue- 
deafness, when the power of recognizing sounds by the ear is alone lost ; 
whilst those cases in which the power of recognizing musical notes by 
the eye has gone are instances of note-blindness. 

In the majority of cases aphasia is due to organic disease of the brain- 
cortex or of the conducting nerve-fibres passing from the cortex to the 
spinal cord. It may, however, be of hysterical origin, or it may be a 
phenomenon of reflex inhibition produced by irritation of the stomach, 
intestine, etc. It is sometimes caused by simple brain-exhaustion, and 
may be one of the symptoms of a violent nerve- storm, such as a migraine. 
In organic aphasia occurring in right-handed persons the lesion is prac- 
tically always in the left cerebral hemisphere 5 in completely left-handed 
persons it is usually in the right hemisphere. In ambidextrous persons 
the speech- centre probably follows the use of the hand in writing ; or, 
to speak more accurately, the use of the hand follows and indicates 
the lesion of the speech- centre. Thus, in a case seen by H. C. Wood, 
in which the person was right-handed for all acts except writing, a left- 
handed palsy — that is, of the writing hand — was accompanied by aphasia. 

It is probable that the original failure of the right hemisphere to de- 
velop its speech-centres is due to habitual disuse not only in the infancy 
of the individual but through successive generations. In some indi- 
viduals it is possible to develop the right third frontal convolution after 
the destruction of the left, so that the power of speech shall be restored. 



486 



DISEASES OF THE NERVOUS SYSTEM. 



(Tuke and Fraser, Journal of Mental Diseases, 1892.) There is plausi- 
bility in the view held by some neurologists that the familiar words 
"yes" and "no," which often remain in aphasia due to a severe left- 
sided lesion, have their origin in the right cerebral speech- centre, which 
has attained sufficient development to compass a few rudimentary expres- 
sions. 

The cortical localization of aphasia may be summed up in accordance 
with the elaborate paper of Wylie as follows : 

Fig. 11. 



/ 




The posterior half or three-fourths of the left first temporal convo- 
lution is the auditory speech-centre, in which are stored the auditory 
speech-images (A) : paralysis of it causes word- deafness. The third frontal 
or Broca's convolution is the centre for the motor memories of speech 
(J5) : paralysis of it causes motor aphasia. The angular and supramarginal 
convolutions constitute the centre for the visual images of written and 
printed speech (G) : paralysis of it causes word-blindness. The posterior 
extremity of the second frontal convolution (D) * is the graphic motor 
centre, in which are stored the motor memories which guide the right 
hand in the act of writing : paralysis of this centre causes agraphia. 
Edgren places the centres for tone- deafness in the first and second tem- 
poral convolutions of the left side, just in front of the position of word- 
deafness (D). 

It is evident that disturbances of the speech-function must result from 
injuries of nerve-fibres which start in the cortical centres. It is believed 

* It is doubtful, however, whether this centre can be yet definitely fixed. We 
can write with the left hand, and even with the teeth, which are believed to have no 
connection with this centre. Wernicke thinks that the visual images are the im- 
portant ones in writing ; but the congenitally blind, who have no visual images, 
can be trained to write. We know of no recorded case in which the lesion was 
strictly limited to the centre D. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 487 

that these fibres are of two sorts : first, commissural fibres joining cen- 
tres ; second, main pathway-fibres passing downward to the various lower 
ganglia : hence there are transcortical and subcortical aphasias. 

The theory of transcortical aphasia rests chiefly upon disturbances 
of speech which have been noted as the results of lesions of the insular 
lobule in the fissure of Sylvius. It is an established fact that lesions of 
the left insula in some cases produce an aphasia, in others do not ; and 
it is held by various authorities that the insula is a meeting-place for 
commissural fibres from the various cortical speech- centres, where it may 
be that they are all brought in contact with a centre of ideation. 

The course of the main pathway downward from the speech- centre 
is not perfectly known. The most probable view is that in the centrum 
ovale the impulses travel through the band which lies under the poste- 
rior third of the third frontal convolution (pediculo -frontal band of Pitres). 
According to Brissaud, the fibres are associated with those going to the 
face, both in the internal capsule (in the region of the knee) and in the 
cms. 

It is often important to distinguish between a subcortical and a centric 
aphasia. In a subcortical aphasia the power of word-thought remains, 
the motor fibres traversing the pathways mentioned being alone affected, 
so that the symptoms are those of a pure ataxic aphasia (without sensory 
aphasia). The conducting fibres from the graphic centres probably pass 
with the arm-fibres through the internal capsule, so that in a subcortical 
aphasia there is no agraphia, unless the lesion in the internal capsule is 
large enough to paralyze the arm and face. 

Conditions allied to Aphasia.— There are certain disorders of 
memory, often the result of organic disease, which are closely allied to 
aphasia. Apraxia is a condition in which the patient has more or less com- 
pletely forgotten the nature and use of objects about him. For example, 
he attempts to use a knife for a spoon, to eat a piece of soap, or to write 
with a fork. All the senses may be involved in this condition, or only 
one form of perception may fail to awaken old memories. Thus, in 
object-blindness (soul-blindness, mind-blindness), which is very often asso- 
ciated with word- blindness, the patient is not able to recognize things or 
persons by sight, but recognizes them by hearing when they give forth 
sound. For instance, he will not know his intimate friends on looking 
at them, but may recognize them at once when they speak to him. 

CEREBELLAR LOCALIZATION. 

Lesions of the cerebellar peduncles sometimes produce rotatory move- 
ments (movements of manege) along the long axis of the body. Ac- 
cording to Eosenthal, the diagnostic symptoms of tumor of the cerebellar 
peduncle are headache, vertigo, disorders of the special senses, hemi- 
plegia, unsteady gait with a tendency to fall upon the side, and partial 
rotation along the vertical axis with lateral rotation of the head. Cer- 



488 



DISEASES OF THE NERVOUS SYSTEM. 



tainly, however, lesions of the cerebellar peduncles are not always accom- 
panied by rotatory movements. 

Titubation is characteristic of disease of the middle lobe of the cere- 
bellum. In it the feet are held well forward and widely separated from 
each other. If the attempt be made to bring them close together, peculiar 
movements of extension and flexion will occur in them, and at the same 
time the body will begin to rock and stagger more and more violently, 
until, in extreme cases, the subject falls unless he can seize some support. 
In unusual instances the movements are definite and in one direction, 
but commonly they are irregular and vary both in direction and in force. 
The staggering may be so great that the patient is unable to move a step. 
Very commonly it is impossible for him to turn suddenly without falling. 
The symptoms may or may not be intensified by darkness or by closing 
the eyes. The walk resembles that of an intoxicated man. There is a 
similar staggering, with to-and-fro movements of the whole body, result- 
ing in a zigzag instead of a straightforward progression. In most cases 
the feet are raised only a short distance from the ground, and are moved 
with a peculiar irregularity of step. 

In rare cases there is a marked tendency to fall or run backward or, 
it may be, forward. The differentiation of titubation from ataxia is aided 
by the facts that in cerebellar disease the patient, lying in bed, is able 
to move the legs with normal promptness and accuracy, and that the 
arms are never affected. 

DISEASES OF THE MEMBRANES OF THE BRAIN. 

PACHYMENINGITIS. 

Definition. — Inflammation of the dura mater. 

Pachymeningitis Externa is an inflammation of the external layer of 
the dura mater, which is probably always secondary to traumatism, dis- 
ease of the skull, or septic infection. There are no distinctive symp- 
toms. Headache is usually, but not always, present, and there may be 
delirium, convulsions, or cortical pressure palsies. The treatment is that 
of the original disease, with local measures as indicated. 

Pachymeningitis Interna, an inflammation of the internal layer of the 
dura mater, may possibly occur in purulent form as a result of sepsis. 

Pachymeningitis Interna Scemorrhagica (Kwmatoma of the Pur a Mater) 
is produced by traumatism, alcoholism, syphilis, sunstroke, and other 
causes. After death there is found in some cases a subdural hemor- 
rhage with little show of membrane, in other cases a large develop- 
ment of subdural membrane with but little hemorrhage. More com- 
monly there is abundance both of the subdural membrane and of the 
hemorrhage. Two views are held by authorities as to the relations of 
the hemorrhage and of the membranes, some teaching that the mem- 
branes precede the development of the hemorrhage, others that the 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES . 489 

hemorrhage precedes the membrane. The probabilities are that the pri- 
mary change is an inflammatory formation of membrane, but that in 
some cases the hemorrhage occurs almost at the onset of the disease. In 
old cases there is often an associated atrophy of the convolution. The 
symptoms of hemorrhagic pachymeningitis are indefinite : excessive 
headache with somnolence, and with a history of the causes previously 
enumerated, should give rise to the strongest suspicion of the disease. 
Apoplectic attacks, convulsions, optic neuritis, even hemiplegia, may be 
secondarily produced by hemorrhage from the delicate vessels in the in- 
flamed membrane. Treatment is rarely satisfactory in its results, but 
severe repeated counter-irritation, especially by the actual cautery, with 
the continuous administration of minute doses of the mercurials and of 
the iodides, may be useful in the earliest stages of the disease. Opium 
may be employed for the relief of pain. 

LEPTOMENINGITIS. MENINGITIS. ARACHNITIS. 

Definition. — Inflammation of the pia mater and arachnoid. 
It is necessary to recognize three forms of leptomeningitis, — acute 
meningitis, acute tubercular meningitis, and chronic meningitis. 

ACUTE MENINGITIS. 

Definition. — An acute inflammation of the pia mater and arachnoid. 

Etiology. — Although a bacterial invasion is the probable cause of 
all acute meningitis, a distinction is to be drawn between primary and 
secondary varieties, according to the circumstances of the infection. 
Under the former are included the sporadic and epidemic cases. Sec- 
ondary forms include those originating in a variety of ways. 

Sporadic and epidemic cases probably originate from the same cause or 
causes, and, especial importance is to be attached to the presence of bac- 
teria, particularly the pneumococcus and streptococcus. 

The secondary variety is also of probable infectious origin, the bacteria 
being other than those concerned in the origin of the sporadic and epi- 
demic cases. They enter the membrane from without, probably through 
blood-vessels or lymph-vessels. Thus, a secondary meningitis may result 
from wounds of the scalp, erysipelas of the face and scalp, phlegmonous 
inflammation of these regions, inflammation of the middle ear, chronic 
nasal catarrh, and operations upon the head. A secondary meningitis 
may also result from a remote infectious process, as pleurisy, pneumonia, 
abscess and gangrene of the lung, and the various infectious diseases, 
also from the amoeba coli communis. 

An apparently acute meningitis may also be produced by gout, rheu- 
matism, sunstroke, Bright' s disease, and syphilis ; but in such cases the 
attack is usually, if not always, an exacerbation of a chronic meningitis 
whose symptoms may have been so mild as not to have been apprehended. 



490 



DISEASES OF THE NERVOUS SYSTEM. 



Morbid Anatomy. — The anatomical changes in acnte leptomeningitis 
are essentially the same as those found in cerebro- spinal meningitis (see 
article on cerebro -spinal meningitis), and consist in a sero- and fibrino- 
purnlent infiltration of the meshes of the pia mater, a focal cortical 
encephalitis, and acute ventricular dropsy. 

Symptomatology. — In a typical case of acute meningitis there is rap- 
idly developed, with or without a chill, an intense headache with parox- 
ysmal exacerbations, intensified by loud sounds or light, soon followed by 
delirium with high fever, and by stiffness of the neck, due to contractions 
of the posterior muscles. Vomiting occurs early and repeatedly. Gen- 
eral or partial convulsions may take place. In the continuance of the 
case, strabismus, ptosis, contraction, dilatation, or inequality of the pupil, 
and disturbances of vision or of hearing, indicate the involvement of the 
cranial nerves. The pulse is usually rapid unless there is irritation of 
the pneumogastric centres, when it becomes slow. There is generally 
pronounced fever, but the range of temperature varies greatly according 
to the cause of the disease. 

Optic neuritis may occur early in the disease ; later, coma, paralysis, 
and other decided symptoms of brain-pressure are developed. 

Diagnosis. — When a meningitis has gone so far as to involve the 
cranial nerves the diagnosis is usually easy, but in the early stages it is 
often impossible in view of the fact that all the symptoms of the early 
meningitis may be produced by pneumonia, typhoid fever, or other acute 
disease, without any organic alteration in the brain-membranes. 

Prognosis. — The prognosis of acute meningitis is always grave. It 
is largely dependent upon the nature of the cause of the attack. 

Treatment. — The treatment of an acute meningitis usually resolves 
itself into the treatment of the concomitant condition, along with local 
blood-letting, persistent application of cold to the head, and persistent 
use of counter-irritants in the form of blisters over the sh,aved scalp. 
Calomel should be given freely to mild salivation unless contra-indicated 
by sepsis or other general condition. If the disease be due to extension 
of inflammation from the middle ear, surgical interference should be 
immediate. 

In debilitated or cachectic children under two years of age occurs a 
variety of acute meningitis which affects chiefly the posterior portion of 
the base of the brain in the region of the cerebellum (posterior menin- 
gitis), and often by closing the foramen of Magendie (occlusive meningitis) 
produces an acute hydrocephalus. In most fatal cases the exudation is 
largely purulent. It is found not only at the base of the brain, but also 
in the choroid plexuses, the velum, and the ependyma of the third ven- 
tricle, whilst the serous fluid frequently distends not only the lateral 
ventricles, but also the fourth ventricle. The symptoms are especially 
characterized by the slowness of their development, and by an early, 
very persistent, and severe retraction of the head (cervical opisthotonos). 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 491 

The case may last for weeks, with slow, irregular fever and great weak- 
ness, without other distinctive symptom than that of rigidity of the neck. 
If death does not occur early, chronic hydrocephalus may result. 

TUBERCULAR MENINGITIS. 

Definition. — A meningitis associated with tubercles in the brain- 
membranes, especially in the pia mater, and due to the presence of the 
tubercle bacillus. 

Etiology. — Tuberculous meningitis is probably always secondary to 
a tubercular deposit elsewhere, and is often a part of an acute general 
tuberculosis. Heredity is a strong predisposing cause. 

Morbid Anatomy. — The tubercles are usually in the form of grayish- 
white granules near the vessels, because of their formation in the peri- 
vascular sheaths. They especially affect the branches of the middle 
cerebral artery, particularly those going to the perforated space. The 
associated inflammatory exudation is commonly more abundant at the 
base, and is fibrino-purulent, involving generally the Sylvian fissure, 
and not rarely giving rise to some distention of the ventricle. The 
cerebral substance is often superficially infiltrated, and spots of softening 
may be present. 

Symptomatology.— In the great majority of cases the disease de- 
velops insidiously in feeble children, who fail in appetite, become extraor- 
dinarily peevish and irritable, and suffer from malaise, headache, con- 
stipation, irregular, disturbed sleep, loss of flesh, and wandering pains. 
Usually after two or three weeks, sometimes after a much longer period, 
the meningitic symptoms develop suddenly, it may be with a convulsion, 
followed by fever, violent headache, giddiness, vomiting, and delirium 
or stupor. Usually the child lies in bed in an apathetic unrest, com- 
plaining bitterly of loud sounds, bright lights, or any disturbance. Even 
during stupor the child utters a peculiar sharp scream (hydrocephalic 
cry), probably extorted by a pain through the head. During this first 
period (stage of irritation) the fever may reach 103° F., and there are 
sudden startings, outbreaks of delirious terror, twitchings of the muscles, 
and some rigidity of the neck. In the second period (stage of oppres- 
sion) the stupor becomes more pronounced, and the general muscular re- 
laxation extreme: the pupils are unequal or dilated; the respiration is 
sighing, often irregular ; the pulse is slow and intermittent ; the bowels 
are obstinately constipated. Vomiting is often severe. The fever tem- 
perature is irregular, varying from below the norm to 102.5° F., having 
no regularity of rhythm, rising and falling, it may be, several times in 
the twenty-four hours. The skin is dry and harsh. If the finger-nail 
be drawn across the skin, the tache cerebrate (a red line) will appear ; it 
is without diagnostic significance. Gradually the patient with developing 
blindness and deafness sinks into the last stages of paralysis, with com- 
plete coma, low delirium, and general or partial convulsions. There are 



492 



DISEASES OF THE NERVOUS SYSTEM. 



also optic neuritis, strabismus, and ptosis, rapid, irregular, feeble pulse, 
and all the symptoms of a profound typhoid state. Death occurs ordi- 
narily between the tenth and the thirtieth day. Local paralyses, mono- 
plegia, and even hemiplegia may appear in the later stages of the disease. 
There may also be diarrhoea or lung- complications as the result of the 
wide-spread tuberculosis. 

In some cases remissions give hope of recovery, but they are usually 
of short duration. In the last days Cheyne- Stokes breathing is not rare, 
and a sudden rise of bodily temperature (even to 109° F.), followed by 
an abrupt fall (even to 94° F. ), often precedes death. 

Diagnosis. — In the earliest stages the diagnosis may be between 
typhoid fever, simple meningitis, and tubercular meningitis. The sever- 
ity of the headache, the vomiting, and the constipation usually distin- 
guish it from typhoid fever, but if there should be abdominal tuber- 
culosis and consequent diarrhoea and tympanitis a mistake is possible, 
so that it is often well to reserve the opinion until stiffness of the neck, 
ocular palsies, or involvement of special senses make the case clear. In 
syphilitic and rachitic children a meningitis occurs which can be dis- 
tinguished from the tubercular form only by its yielding to treatment. 

Prognosis. — The disease probably always ends fatally. 

Treatment. — There is no specific treatment : the good results which 
are alleged to have followed the use of calomel have probably been due 
to the reported cases having been of specific origin. Whenever there is 
a suspicion of syphilis or of rachitis, appropriate medication should be 
actively employed. 

CHRONIC MENINGITIS. 

Chronic meningitis is usually due to sunstroke, to trauma, or to 
syphilis, but may result from an acute inflammation, and in the majority 
of cases involves to a greater or less degree the cortex, through its in- 
fluence on the brain- arteries, which run from the pia mater directly to 
the cortex. Its treatment varies so much with its cause that the former 
will be discussed under cerebral syphilis and sunstroke. In traumatic 
general meningitis the treatment consists of continuous severe counter- 
irritation and the use of minute doses of mercurials and the iodides for a 
long time, with abstinence from all mental labor and excitement. 

DISORDERS OF THE CEREBRAL CIRCULATION. 

CEREBRAL ANAEMIA. 

Definition. — Deficiency of blood in the brain. 

Symptomatology. — Acute cerebral anaemia (syncope), as after hemor- 
rhage, produces tinnitus aurium, a sense of general weakness or faintness, 
disorder of the special senses, cold sweat, loss of consciousness, dila- 
tation of the pupil, general convulsions, and death from failure of the 
respiration. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 493 

Chronic brain- anaemia is affirmed to cause vertigo, apathy, tinnitus 
aurium, sleeplessness, loss of memory, and hallucinations. Under the 
name of spurious hydrocephalus, Marshall Hall described a condition which 
in feeble children is especially apt to follow excessive diarrhoea, and has 
been mistaken for tubercular meningitis, on account of the semi- coma, 
convulsions, and retraction of the head ; but there is no fever, and the 
pulse is rapid throughout. How far these symptoms are due to lack of 
blood in the brain and how far to simple exhaustion remains unsettled. 

Treatment. — In syncope the patient should be placed in a recum- 
bent position, cold water dashed in the face, the nostrils irritated by 
ammoniacal exhalations, and strong alcoholic drinks administered. In 
severe, persistent cases strychnine, tincture of digitalis, nitroglycerin, 
may be given hypodermically ; if these fail, a pint of tepid weak saline 
infusion may be injected into the buttocks, or transfusion may be prac- 
tised. In chronic brain- anaemia the indication is to cure the anaemia and 
exhaustion by appropriate measures. 

Cerebral oedema or serous apoplexy may occur as an acute, severe con- 
dition in chronic Bright' s disease, and be associated with coma, convul- 
sions, inequality of the pupils, and even partial hemiplegia, so as closely 
to simulate true apoplexy. 

The question how far the oedema is the cause of these- symptoms is 
an exceedingly difficult one to answer. Undoubtedly most if not all of 
them may be produced by uraemia without oedema, but it is very doubt- 
ful whether a pure uraemia will produce localizing symptoms such as in- 
equality of the pupils and partial hemiplegia. In brain- atrophies and in 
extreme passive hyperaemia there is often an excess of serous fluid in 
the brain. Local brain- cedemas, probably from local interference with 
the circulation, occur in the neighborhood of tumors and other cerebral 
lesions. 

CEREBRAL HYPEREMIA. 

The subject of cerebral hyperaemia is one of great obscurity, the diag- 
nosis being continually made by practitioners of medicine as a means of 
accounting for various obscure cerebral disturbances, such as are seen in 
cerebral asthenia from overwork. It is possible that weakness of the 
cerebral vessels from habitual overuse may exist in these cases, but there 
is no proof of the truth of the supposition. Again, the sleeplessness, 
headache, giddiness, apathy, somnolence, slight mental confusion, etc., 
which are often seen in diseases of the heart, in chronic emphysema, in 
tumors at the root of the neck or in the mediastinum, are attributed 
by many, with a show of reason, to passive or venous congestion of the 
brain. In many of these cases, however, the symptoms are probably 
largely due to the presence of carbonic acid and other poisons in the 
blood. 

The headaches, with red face and throbbing carotids, occasionally met 



494 



DISEASES OF THE NERVOUS SYSTEM. 



with in persons of fall habit, and relieved by a mercurial or other brisk 
purge, may be ascribed to an acute cerebral congestion. There are 
undoubtedly rare cases of sudden attacks, with a sense of great fulness 
in the head, turgid, red face, throbbing carotids, vertigo, and finally, it 
may be, complete unconsciousness. Such attacks may simulate an apo- 
plexy and be at once relieved by bleeding. The cause of these attacks 
is entirely obscure : the congestion, so far as can be made out, is pri- 
mary. It is probable that in some cases of true hemorrhagic apoplexy 
the attack is not hemorrhagic from the beginning, but simply congestive, 
a diseased blood-vessel giving way from the strain of a local increased 
blood-pressure. In apoplectic attacks following violent sudden emotion, 
a primary cerebral hyperemia with a secondary cerebral hemorrhage is 
probably the history. 

Eare cases occur in young children of deep sleep or semi -coma with- 
out obvious cause, lasting, it may be, for some hours. These have been 
explained as instances of acute cerebral hyperemia. The difficulty in 
all such cases is, first, that there is no proof of the existence of the 
cerebral hyperemia ; secondly, that at present there seems no way of 
explaining the occurrence of the cerebral hyperemia. 

Treatment. — When cerebral hyperemia simulates apoplexy a free 
venesection may be called for. In less severe cases leeches should be 
applied to the temples, or cups to the back of the neck, and a drastic 
purgative administered. 

DISEASES OF THE BLOOD-VESSELS OF THE BRAIN. 

CEREBRAL THROMBOSIS AND EMBOLISM. 

Definition. — Arrest of circulation in the brain by embolic or throm- 
botic occlusion of a vessel. 

Etiology. — The causes of the formation of emboli and of thrombi in 
the brain are the same as those which act in other portions of the body. 
The results are more serious, on account of most of the cerebral arteries 
not anastomosing, so that it is not possible for a collateral circulation to 
be set up. 

Morbid Anatomy. — Any of the brain- vessels may be involved. It 
is, however, very unusual for the cerebellar arteries to be affected by an 
embolus, which, following the direct line of blood- current from the heart, 
naturally passes up the left carotid into the left middle cerebral artery, 
or, if it be too large, is arrested in the basilar artery. Sometimes the 
embolus lodges in the vertebral or the posterior cerebral artery, very 
rarely in the anterior cerebral. 

Symptomatology. — The symptoms produced are those of embolic or 
thrombotic arrest of circulation, and vary with the size and situation of 
. the vessel affected. If the middle cerebral or other large artery be sud- 
denly blocked, there will be loss of consciousness, with hemiplegia, and, 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 495 

in some cases, convulsions. The temperature, usually, is not imme- 
diately affected, but after some hours begins to rise, though it rarely 
reaches above 101° F. The temperature disturbance may be very slight 
and transient or may continue some days. In cases of thrombosis, giddi- 
ness, headache, loss of memory, brief attacks of stupor, and other symp- 
toms due to disordered circulation may precede the final closure of the 
blood-path. Sudden arrest of circulation, even in one of the smaller 
arteries, may be accompanied by an apoplectic attack, but often the loss 
of function is the only symptom. In atheromatous thrombosis there is 
not rarely a creeping hemiplegia : thus, there is a facial palsy, and some 
hours afterwards the arm of the same side weakens, and then the leg. 
One or two days may be required for the full development of the symp- 
toms. In some cases temporary palsies occur, probably as the result of 
the partial formation and the subsequent dissolving of fibrinous throm- 
botic clots. Cutting off the blood-supply produces a change in the brain- 
structure, which is accompanied by softening and discoloration, — red 
softening in the cortex and the ganglia, white softening in the centrum 
ovale. The so-called yellow softening is an advanced stage of the red. 
The softened tissue is composed of disintegrating nerve-fibres, fatty and 
granular debris, and granular corpuscles. When the softening is of 
limited extent the tissue may remain in this condition for months, but 
finally there is absorption, with the deposition of cicatricial tissue, or, 
if the mass has been too large, the formation of a cyst. There is no 
regenerative power in softened brain-tissue. 

The symptoms of arrested brain-function vary almost indefinitely in 
accordance with the seat of the artery which is affected. Whole tracts 
of the brain may be involved, or one centre may be dissected out. Thus, 
there may be a complete hemianaesthesia and hemiplegia, or there may 
be a simple hemianopsia or a purely motor hemiplegia. The follow- 
ing schedule shows the result of the occlusion of the more important 
arteries. 

Carotid Artery. — Occlusion of a carotid artery by tying may cause no 
symptoms, but it may be followed by a hemiplegia, which disappears 
in a short time by re-establishment of the circulation through anasto- 
mosing vessels. If, however, an embolism or a thrombosis forms within 
the skull, there is commonly a progressively increasing clot, which finally 
invades the circle of Willis and causes coma and death, or, if recovered 
from, a hemiplegia or various palsies. 

Vertebral Artery. — Occlusion of a vertebral artery usually produces 
a hemiplegia, which in most of the recorded cases has been upon the 
same side as the occlusion. The tongue, palate, and larynx are affected, 
and there is great impairment of swallowing and of articulation. The 
motor paralysis is sometimes accompanied by partial anaesthesia, and is 
usually temporary, owing to the free anastomoses between the vertebral 
and the anterior spinal arteries. In some cases the involvement of the 



496 



DISEASES OF THE NEKVOUS SYSTEM. 



respiratory centres leads to immediate death, and in certain cases there 
has been a bilateral paralysis, probably due to arterial anomalies. 

Basilar Artery. — Thrombus of a basilar artery may cause a foudroy- 
ant apoplexy, with rise of temperature and death within twenty-four 
hours, or with partial recovery and various localizing symptoms due to 
softening in the medulla and in the pons. The paralysis is often alter- 
nating, and if with a basilar artery the posterior connecting artery is 
affected, there is softening of the cerebral peduncle, which is chiefly sup- 
plied by the direct or ascending portion of the posterior cerebral. The 
artery of the oculo-motor centre, also rising near the origin of the pos- 
terior cerebral, may be affected even when the posterior cerebral is not, 
giving rise to a crossed oculo-motor paralysis. 

Anterior Cerebral Artery. — Obstruction of the anterior cerebral artery 
may give rise to comparatively few symptoms, on account of the free 
anastomoses between this artery and the middle cerebral. There may 
be softening of the olfactory bulb, which is supplied by the first branch 
of the artery, with loss of smell. A monoplegia of the leg might (theo- 
retically) be produced by the softening of the paracentral lobule and 
the neighboring marginal convolution. 

Middle Cerebral Artery. — Occlusion low down causes hemiplegia by 
softening of the anterior portion of the internal capsule, the internal 
ganglia also being affected $ and if the left artery be affected there is 
also aphasia. There is usually some disturbance of sensation, which is 
commonly not permanent. Occlusion above the arteries going to the 
centre of the brain gives rise to cortical paralyses and aphasia (left 
artery) ; occlusion of the first branch causing softening of the third 
frontal, of the second and third branches softening of the ascending 
frontal, and of the fourth branch softening about the posterior limb of 
the fissure of Sylvius with sensory aphasia. Ptosis may occur on the 
side opposite the hemiplegia. (Gowers.) 

Posterior Cerebral Artery. — Obstruction may cause hemianesthesia 
from softening of the tegmentum or of the posterior part of the internal 
capsule, or hemianopsia from softening of the occipital lobe. This artery 
anastomoses with so much freedom that the paralytic effects are often 
temporary. Gowers states that sometimes there is complete temporary 
loss of sight, probably due to reflex inhibition. 

Diagnosis. — The diagnosis between a hemorrhagic and a thrombotic 
. or embolic apoplexy or paralytic stroke can rarely be a positive one, ex- 
cept in cases of congestive apoplexy, the symptoms of arrested circu- 
lation resembling those of the syncopal form of apoplexy. (See page 
501.) If there be cardiac or aneurismal disease capable of furnishing a 
source for the embolus, a diagnosis of embolism may be made, but will 
often be erroneous. Slowness of development, failure of rise of tempera- 
ture, minuteness of paralysis (demonstrating that the lesion is cortical), 
the occurrence of several attacks at short intervals, each attack plainly 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 497 

involving a small territory of the cortex, point towards thrombosis, but 
may all coexist in a case of hemorrhage. Spasmodic contractions and 
pronounced fever are strong indications of hemorrhage. 

Prognosis. — The prognosis is always grave, and is in direct pro- 
portion to the severity of the symptoms. If the paralysis has lasted 
some days, improvement is less to be hoped for than in the hemorrhagic 
disease. 

Treatment. — There is no known means of dissolving an embolus or 
of preventing the formation of a thrombus. Even when thrombosis is 
threatening nothing can be done in the way of prevention, except in 
syphilitic cases. Depleting measures of any kind are harmful. Where 
there is threatened heart-failure, digitalis, alcoholic drinks, and other 
cardiac stimulants may be useful in maintaining the activity of the cir- 
culation, but, unless urgently demanded, may do harm by increasing 
excitement and even forcing the clot onward. In most cases nothing 
should be done but to enforce quiet, feed carefully with a light, nutritious 
diet, and administer calmatives and laxatives as needed. When there 
is syphilis the medication should be actively antispecific. Mercury is 
usually preferable to potassium iodide, as more active. The treatment 
of paralyses resulting from thrombosis does not differ from that proper 
for cases following brain- clot. 

CEREBRAL ANEURISMS. 

Any of the cerebral vessels may suffer from aneurisms, which occur 
in two forms, small miliary multiple enlargements (see Cerebral Hemor- 
rhage, page 499) and single large aneurism. The latter lesion may pro- 
duce symptoms of pressure or of irritation conforming to its position, 
but it may be entirely latent until it produces an overwhelming apoplexy. 
The diagnosis of cerebral aneurism is, except in the rarest cases, a matter 
of grave doubt. Even if a bruit can be heard, it may be only the nor- 
mal murmur which in many individuals can be heard in the temporal 
region. 

THROMBOSIS OF CEREBRAL SINUSES. 

Thrombosis of a brain-sinus may be due to— 1st. Phlebitis, caused by 
infection from general sepsis, erysipelas, furuncle, diphtheria, typhoid 
fever, etc> or by extension of a neighboring inflammation, as in suppura- 
tive otitis, or by traumatism (in one hundred and fifty-one cases collected 
by Worden this occurred once). 

2d. Advanced cachexia (marantic thrombus), as in chronic diarrhoea, 
chlorosis, phthisis, old age, infantile disease. 

3d. Diseases of the venous system, wide-spread degenerations, local 
involvements in tumors, etc. 

Symptomatology. — The symptoms of thrombosis of the brain-sinus 
vary greatly. If only one sinus be involved, the affection may be latent, 

32 



498 



DISEASES OF THE NERVOUS SYSTEM. 



especially in very young infants. Again, the cerebral disturbance may 
be lost in the general symptoms of a violent pysemia ; usually, however, 
violent headache, intense fever, vomiting, delirium, coma, ocular palsies 
or contractions, and optic neuritis, indicate what has occurred. Convul- 
sions may be present. Pulmonary enfbolism may occur by the breaking 
off of small portions of the clot. When in young children the longitudinal 
sinus is attacked, according to Gerhardt and Eichhorst, there is dilatation 
of the veins of the scalp in the region of the grand fontanelle, whilst the 
bregma is depressed from the beginning. When the transverse sinus is 
invaded, the jugular veins of the same side are apt to be affected, and 
there is painful oedema of the ear and mastoid region from implication 
of the posterior auricular veins. Thrombosis of the cavernous sinus is 
shown by the blocking of the ophthalmic vein and the consequent ex- 
ophthalmos, cedema of the upper eyelid, swelling of the conjunctiva and 
face, chemosis, and oculo-motor nerve palsy. 

Diagnosis. — Diagnosis is always difficult, often impossible until evi- 
dences of venous pressure are apparent. When in any case of otorrhcea a 
chill followed by fever occurs along with occipital headache and stiffness 
of the neck or retraction of the head, the diagnosis is sufficiently clear 
for immediate surgical interference. 

Prognosis. — Death is almost invariable in the adult unless surgical 
interference is possible. Eemissions occur, but are very deceitful, al- 
though infants sometimes get well with hopeless damage to the brain. 

Treatment. — No medical treatment is of avail. If a positive local- 
izing diagnosis can be reached, early trephining, evacuation of the sinus, 
disinfection, and drainage are justifiable. 

CEREBRAL HEMORRHAGE. 

Definition. — A hemorrhage into the brain- substance. 

Hemorrhage into the brain-substance is commonly accompanied by 
great disturbance of the consciousness, constituting the apoplexy* of 
ordinary language ; but an apoplectic attack may occur without hemor- 
rhage. Hemorrhage into the brain may occur without distinct apoplectic 



* The term apoplexy means a striking from or a stroke, and might be used for any- 
sudden loss of cerebral function, whether followed by paralysis or not. In this mean- 
ing of the term an apoplexy may be produced by an embolism, by toxaemia, and even 
by a traumatism. Hence some writers use two terms : apoplectic stroke, significant 
of cerebral paralysis accompanied by primary loss of consciousness, and paralytic 
stroke, indicating a sudden cerebral paralysis not accompanied by primary loss of 
consciousness. The word apoplexy is not, however, properly confined in its applica- 
tion to the brain, as it is used to signify a sudden escape of blood into an organ by 
the bursting of a blood-vessel and a consequent momentary paralysis of function. 
Pulmonary apoplexy may be cited as a familiar example. In strictness, the word 
cerebral apoplexy should be used in the text ; but custom warrants the employment 
of apoplexy as equivalent to cerebral apoplexy. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 499 

symptoms, when it is known in the ordinary parlance of the sick-room as 
a paralytic " stroke/' or, sometimes, simply as a " stroke." 

Etiology.— Cerebral hemorrhage, not of traumatic origin, or not 
due to scurvy, leucocythsemia, purpura, and certain infectious diseases, is 
always the result of previous disease of the blood-vessels. Such disease 
may be the outcome of carcinoma or other new growth in the brain, but 
in the vast majority of cases it is an arterio-sclerosis produced by syphilis, 
gout, renal disease, old age, and other causes. (See Arterio-Sclerosis. ) 
Apoplexy is, therefore, much more frequent after the age of fifty j but 
as arterial degeneration is possible at any age, so also is cerebral hemor- 
rhage. Heredity plays an important part in the etiology of apoplexy. 
Not only are there families in which there is an overwhelming impulse 
towards premature arterio-sclerosis, but there are families in which there 
is a distinct tendency to local degenerations of the cerebral blood-vessels, 
and others in which there is proneness to congestive attacks of the brain. 
The disease is more frequent in men than in women, probably because 
of the greater frequency in men of arterio-sclerosis. It is not certain 
that brain-work, even when habitually in excess for years, has any dis- 
tinct influence in the development. The belief that men having the 
so-called apoplectic build or habit — i.e., a stout, thick body with a short 
neck and an habitually red face — are more liable than others to the dis- 
ease is still wide-spread. Cardiac hypertrophy is probably more active 
in its influence. 

In the great majority of cases no exciting cause for an apoplectic at- 
tack can be traced, but a violent emotion or a violent general muscular 
strain has occasionally precipitated the disease by increasing the cerebral 
blood-pressure. Thus, it may happen during defecation, childbirth, slight 
intoxication, etc., and in a number of cases has occurred during coitus, 
especially in old men in houses of prostitution.* 

Morbid Anatomy. — The most important alterations of blood-vessels 
leading to cerebral hemorrhages are the miliary aneurisms first noted by 
Cruveilhier in 1836. They appear as red or black enlargements, about the 
size of a pin's head, scattered along the small blood-vessels. They are 
the results of a chronic inflammation of the external and internal coats 
of the vessels, accompanied by atrophy of the middle coat. According 
to the teachings of Charcot and Bouchard, the primary alteration is a 
sclerotic periarteritis with proliferation of the cellular elements in the 
adventitia, which at first becomes enormously thickened. Zenker and 
also Eichler, however, believe that the alteration begins in the inner coat 
and is, in fact, a chronic endarteritis. The hemorrhage resulting from 
rupture of one miliary aneurism is minute, but usually several give way 
together, with consequent free loss of blood. 



* Birds, stallions, and probably other animals occasionally die of apoplexy during 
copulation. 



500 



DISEASES OF THE XERYOUS SYSTEM. 



In some cases of cerebral hemorrhage the changes of the arteries are 
diffused, not anenrismal j while in rare instances it does not seem possible 
to demonstrate any sufficient change in the vessels. 

Intra- cranial hemorrhages are divided according to their seat into 
meningeal, ventricular, and parenchymatous (into the brain- substance). 

Meningeal hemorrhage, usually the result of gross aneurism or of 
violence, may be between the skull and the dura or more commonly 
subdural, or between the arachnoid and the pia mater. Intra-cerebral 
hemorrhage is more common upon the right than upon the left side, 
and especially affects the region of the corpus striatum and optic thala- 
mus, particularly the outer border of the lenticular body, which is sup- 
plied by the striate artery, — the artery of cerebral hemorrhage. (Char- 
cot.) Intra-cerebral hemorrhage, however, may occur in any portion of 
the brain, and is accompanied by tearing of the tissues, so that a clot 
more or less mixed with brain-substance occupies an irregular cavity. 
Ventricular hemorrhage is rare except as the result of the breaking 
through of an intra-cerebral hemorrhage. Multiple hemorrhages occur, 
and are often distinctly symmetrical. 

The changes which take place in the blood- clot consist in the absorp- 
tion of the liquid portion, probably also of the fibrin, and the conversion 
of the haemoglobin into pigment, reddish-brown haematoidin. If the 
clot is a large one, an irritative inflammation is set up around it, and a 
cyst with defined walls and fluid contents is finally formed; when the 
clot is minute, a dark-colored scar is all that is left. In meningeal hem- 
orrhage degenerations of the convolution involved are very common, 
especially in infants. 

As the result of inflammatory action, a clot of sufficient size, affecting 
motor centres or motor fibres, causes a secondary degeneration which fol- 
lows the motor path downward. Thus, if the clot is cortical, the second- 
ary degeneration passes along the corona radiata, the internal capsule, 
the crus, the pons, the medulla, and the cord, even to the ganglionic cells, 
which, however, do not undergo change. 

Symptomatology. — For the purposes of discussion two types of 
apoplexy may be recognized, although every grade of attack between 
the types occurs. The apoplectic attack may come on with great sud- 
denness. It may, however, be preceded by prodromes, such as head- 
ache, tinnitus aurium, mental confusion, and hemiplegic or monoplegic 
numbness or weakness, which are in some cases affirmed to have lasted 
for some hours. Usually without distinct warning the patient drops 
unconscious, or he may become confused in speech and manner and then 
suddenly be stricken, or else gradually grow more and more heavy and 
finally sink into unconsciousness, or the unconsciousness may be partially 
recovered from and relapse. At the height of the attack the uncon- 
sciousness is complete. The pupil is fixed, dilated or contracted, as the 
case may be. In the congestive form the face and conjunctivae are in- 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 501 

tensely suffused, dark purplish red. The breathing is loud, snoring, and 
stertorous from the paralysis of the palate. The pulse is usually full and 
bounding. It may be slower or more rapid than normal ; occasionally it 
is small and hard. The surface is warm. In the syncopal form the face 
is pale and the breathing quiet, or, if stertorous, not loud and harsh in 
its sound. The surface is coolish, and the pulse rapid and feeble. In 
either type of apoplexy paralysis may reveal itself by drawing of the 
mouth or puffing of the lips upon one side more than upon the other, or 
by absence of motion in one arm or one leg ; the general relaxation may, 
however, be so extreme as completely to mask the paralysis. 

Convulsions may occur in any stage of an apoplexy. The apoplexy 
may end in death, which may take place in a few minutes, but is usually 
delayed for many hours. The unconsciousness remains complete; the 
pulse, whether originally strong or feeble, continually falls in force ; the 
respiration grows more and more shallow, or more and more irregular, 
and may at last gradually die away or suffer sudden arrest. The cere- 
bral reflexes are frequently lost early in a case of severe apoplexy, 
especially when the basilar region is invaded by the lesion. Thus it is 
that the power of swallowing is affected. Complete loss of this function 
is an almost invariably fatal sign. In a favorable case there is usually 
a gradual return to consciousness, but the awaking may be sudden. 

The subject of temperature in apoplexy needs further elucidation. 
Usually in a severe case the temperature falls immediately, but, accord- 
ing to Dana, in fatal cases it rises during the twenty-four hours to 102° F. 
or beyond, to undergo a slight fall the next day unless death intervenes. 
Except early in the attack, the axillary temperature of the paralyzed side 
is commonly one-half to one degree higher than on the sound side. A 
very great rise of temperature may occur in uncomplicated fatal cases (to 
105° or even 107° F.) ; when the lesion is in the hemispheres such rise of 
temperature is of very serious import, and usually ends in death. Lesions 
in the pons commonly produce high fever, even when recovery takes place. 

The initial symptoms of cerebral hemorrhage may vary decidedly 
from those given. If the clot be in the medulla, the patient may fall 
unconscious and die from arrest of respiration inside of two or three 
minutes. If the hemorrhage be small, and be situated in a not very 
sensitive portion of the brain, the only manifestation may consist of 
vertigo or sudden headache, followed by very brief loss of consciousness, 
or even by simple mental confusion, during which nausea and vomiting 
frequently occur. If such an attack occur at night, the patient may 
pass into it without wakening, and have no knowledge of his illness 
until an attempt at movement in the morning reveals the hemiplegia. 

A very frequent symptom in apoplexy is that of the so-called conju- 
gate deviation of the eyes and head. In the majority of cases the eyes 
and head are drawn powerfully towards the lesion, — that is, away from 
the paralyzed side of the body ; but in exceptional cases the deviation is 



502 



DISEASES OF THE NERVOUS SYSTEM. 



in the opposite direction, the face looking away from the lesion. The 
law formulated by Vulpian and Prevost, that in lesions of the hemi- 
sphere the head is drawn towards the lesion and away from the paralysis, 
whilst in lesions of the mesencephalon it is drawn away from the lesion 
and towards the paralysis, certainly has exceptions. Conjugate devia- 
tion may occur without the loss of consciousness ; it is commonly accom- 
panied by quietude of the eyeballs, but there may be marked nystagmus. 
It is usually fugitive, in most fatal cases disappearing before death, but 
it has persisted for months or years. The muscular irritation which 
shows itself in the symptoms just spoken of may also give rise to a gen- 
eral rigidity of the muscles which is especially apt to occur in the side 
opposite the hemisphere. During the condition of unconsciousness the 
knee-jerks and other reflexes are usually abolished. 

When the patient survives twenty-four hours in a condition of coma, 
or even, in exceptional cases, with return to consciousness, a reaction 
may occur with marked evidences of brain- irritation. At such time the 
rigidity of the extremities is pronounced, and is often associated with 
heightened reflexes. It is now that the trophic changes appear, the most 
serious being the so-called decubitus. This begins usually on the buttock 
as a patch of erythema, dark red or violet in color, disappearing momen- 
tarily upon pressure, but soon giving origin to vesicles or bullae whose 
contents are usually opaque and bloody. The bullae soon pass into ulcer- 
ation, leaving a raw, bluish or violet surface with swelling and sanguino- 
lent infiltration of the tissues beneath. In the course of a few hours the 
ulcer becomes blackish, and there is formed a smaller or larger slough, 
whose separation may lay bare the deeper muscles with the nerve-trunks 
and arteries, or even the bone. The decubitus is always on the paralyzed 
side. 

It may be that the pulmonic congestion which so commonly compli- 
cates apoplexy is the result of trophic irritation, but the fact that it is 
very prone to be in excess in the lung of the paralyzed side suggests 
that it may be due to the disordered action of the respiratory muscles. 

The motor paralysis which remains behind a cerebral hemorrhage de- 
pends for its position and completeness upon the seat and the size of the 
clot. The ordinary form of the paralysis is a simple hemiplegia, involv- 
ing the face, arm, and leg. The facial palsy is rarely sufficiently complete 
to affect the soft palate ; the hypoglossal nerve is affected a little less fre- 
quently than the facial. The two palsies of face and tongue unite to pro- 
duce the characteristic thickness of speech of the recent hemiplegic ; and 
whilst, owing to the almost universal escape of the motor root of the 
trigeminal nerve, there is no loss of the power of mastication, the failure 
of the cheek-muscles (supplied by the facial) makes mastication difficult 
from the inability to retain the food between the teeth. 

As a rule, the arm is more completely paralyzed than the leg ; of the 
muscles of the trunk the trapezius is the only one which is commonly 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 503 

much affected. The universal escape of the muscles of the eyes, thorax, 
and abdomen, which are associated in symmetrical movements, is usually 
explained upon the theory of Broadbent, which is that in the case of 
muscles which are habitually associated in function there are commissural 
fibres in active life between the spinal ganglia or nuclei, so that brain- 
impulses pass over from one nucleus to the other, a right nucleus giving 
to the left nucleus a portion of the impulse which it has received from 
the left cortex, and vice versa. If this be so, it is evident that when 
one side of the brain is injured both nuclei may be innervated from the 
remaining hemisphere. It is possible, however, that the commissural 
fibres may really exist higher up, uniting the cerebral and not the spinal 
nuclei, or that these associated muscles may receive nerve-fibres from 
both the direct and the crossed cerebral tracts, and so be normally inner- 
vated from each hemisphere. 

Pronounced disturbances of sensation are not common in hemiplegia, 
but hemianesthesia, with or without implication of the special senses, 
may exist. It is evident that, as a cerebral hemorrhage is a focal lesion, 
instead of there being a hemiplegia there may be a monoplegia; that 
instead of the paralysis throughout being on one side it may be crossed ; 
or, in other words, that there may be any association of symptoms which 
is in obedience to the laws of cerebral localization heretofore enunciated. 

The after-history of cerebral hemorrhage varies. In favorable cases, 
with a small clot, the paralysis may disappear in a few days. More 
commonly partial recovery only is attained. The improvement begins 
in from a few days to a few weeks, and is commonly greater in the 
leg than in the arm : so that a hemiplegic often can walk although the 
arm is perfectly useless. The gait of the hemiplegic is, however, seldom 
perfect ; the leg is dragged, and especially is it prone to be raised from 
the ground by an elevation of the pelvis rather than of the knee ; or both 
knee and pelvis may be required to raise the foot sufficiently to clear the 
toes, which droop from the inability of the anterior tibial group to hold 
them up. In either case the whole limb is usually thrown outward and 
forward in a semicircle instead of being simply carried forward. The 
shoulder -joint is commonly the last part of the arm to regain its move- 
ments. Owing to the contractures of the muscles, there is in most cases 
some flexure of the arm at the elbow and at the wrist, whilst the fingers 
are more or less clenched. 

Two forms of muscular rigidity occur in hemiplegia, in each case with 
heightened reflexes. Early rigidity developing immediately after the 
formation of the clot appears to be the outcome of inflammation around 
the clot, and is absent in favorable cases. Late rigidity comes on with 
the secondary degeneration of the pyramidal tract, and is generally be- 
lieved to be due to an irritation of the pyramidal fibres similar to that 
which occurs in lateral sclerosis. This seems to be correct, although 
the theory that the contractures are produced by the habitual position 



504 



DISEASES OF THE NERVOUS SYSTEM. 



taken by the paralyzed limb has a certain degree of plausibility. The 
latter explanation does not, however, account for the increased activity 
of the reflexes which always accompanies late rigidity. Atrophy of 
the paralyzed muscles is usual after many years, but is not of a de- 
generative character, so that the paralyzed muscles long retain their 
normal relations to electricity. How far the joint- inflammation, espe- 
cially in the shoulder, and the peculiar enlargements which sometimes 
occur in the peripheral nerve-trunks of the paralyzed side, should be 
looked upon as trophic, is uncertain. In rare cases rapid and pro- 
nounced atrophy of the muscles follows a cerebral hemorrhage, and may 
be remarkably out of proportion to the degree of the paralysis. Accord- 
ing to Quincke, it may continue after the paralysis has disappeared, and 
is therefore not an atrophy of inaction. The fact that there is neither 
qualitative nor quantitative alteration of the electric excitability of the 
muscles shows that the atrophy is not due to any disturbance of the 
lower trophic centres of the spinal cord. Quincke believes that the 
brain contains nerve-fibres which have distinct relations with nutrition, 
and which pass through the hinder end of the internal capsule. 

After cerebral hemorrhage, especially in children, various motor dis- 
turbances may occur, many of which have been commonly spoken of as 
distinct diseases, such as athetosis, tremors, choreiform movements, etc. 
They are no more diseases than is the late rigidity of the muscles, but 
the importance of the late results of cerebral hemorrhage in childhood 
warrants special notice of them. (See page 508.) 

A peculiar very slow arthritis, first pointed out by Charcot, may de- 
velop in hemiplegia, and is often mistaken for chronic rheumatism, from 
which it pathologically differs in having a tendency to the formation 
of purulent effusion and to the destruction of the cartilages and bone. 
During life the trophic arthritis is to be recognized by the following 
points : first, the hemiplegic arthritis develops about the time at which 
late muscular contractures usually come on, and, at least in the early 
stage, is limited to the paralyzed side ; secondly, the pain may be mod- 
erate, but the tenderness to touch or to movement is excessive ; thirdly, 
the swelling, which is pronounced, develops rapidly, and is accompanied 
by distinct oedema, with pitting on pressure. 

Diagnosis. — The diagnosis between hemorrhagic and thrombotic apo- 
plexy having been sufficiently dwelt upon (see page 496), in the present 
paragraph the word apoplexy is used in its widest significance. Whilst in 
private life, with a full history of the attack, the recognition of an apo- 
plexy is usually easy, in public practice, without a history of the case, 
mistakes may be easy, especially when drunkenness masks the symptoms 
of the cerebral lesion. Very careful examination of the head for possi- 
ble traumatism in such cases should first be instituted. Whenever by 
shaking, shouting in the ear, etc., a drunken person cannot be aroused, 
the probabilities of cerebral hemorrhage are strong enough to justify 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 505 

the temporary diagnosis. A very careful examination should be made 
for evidences of paralysis. Its existence warrants the diagnosis of 
apoplexy. 

Unequal pupils may be produced by poisoning,* but are prima facie 
evidence of apoplexy. Drawing of the face to one side is, of course, 
decisive, and if in breathing the air comes out with a sort of puff and 
pulling of one corner of the mouth, the case is one of cerebral hemor- 
rhage. If the patient be restless, the motionlessness of the arm or leg of 
one side will usually betray a hemiplegia, or upon raising the extremities 
and allowing them to fall, those of one side will be found to drop much 
more heavily than do their fellows. 

The absence of demonstrable paralysis is not proof that a case is not 
apoplexy, as a severe hemorrhage into the brain may produce a gen- 
eral muscular relaxation ; if, however, in such case any measure of capa- 
bility of being aroused remains, the probabilities of apoplexy are very 
small. Conjugate deviation or any monoplegic or hemiplegic spasm justi- 
fies the diagnosis of apoplexy. A general convulsion may readily be of 
alcoholic or uremic origin. 

It is sometimes impossible to make an immediate diagnosis between 
the quiet form of uraemia and cerebral hemorrhage, especially since in 
uraemia there may be hemiplegia. In every case brought into a hos- 
pital unconscious the urine should be at once examined ; but, as cerebral 
hemorrhage often occnrs in advanced kidney disease, care is necessary in 
interpreting the results of such examination. A distinct rise of tempera- 
ture makes the diagnosis of simple uraemia very improbable unless there 
be a series of very violent convulsions. In doubtful cases the physician 
should be cautious in making positive statements as to the nature of the 
attack. 

The recognition and localization of a meningeal or of an extra- dural 
hemorrhage after head-injuries are of great importance and difficulty. 
Whenever symptoms of cerebral compression develop, and still more 
imperatively whenever convulsions, paralyses, inequality of the pupil, 
localized spasms, or other evidences of cortical irritation or loss of power 
appear, shortly after a blow upon the head, the probabilities of a menin- 
geal hemorrhage are sufficient to demand trephining. The temperature 
may be subnormal or as high as 104° F. The difficult cases are those 
with irregular symptoms : thus, the appearance of the hemiplegia has in 
reported cases been delayed for a week ; further, large clots have been 
found after death in the membranes although during life there were no 
motor symptoms. If in any case after a head-injury lost consciousness 
is regained and after a short time again lost, an operation should be per- 
formed at once, whether there be or be not convulsions. When there are 
no localizing symptoms it may be impossible to determine whether the 



* I have seen them in opium poisoning. (H. C. Wood.) 



506 



DISEASES OF THE NERVOUS SYSTEM. 



clot exists at the seat of the blow or upon the opposite side. Under 
such circumstances trephining should be practised first at the point of 
violence, then, if nothing be found, upon the opposite side. As the 
middle meningeal is the artery especially liable to rupture, in a doubtful 
case it may be the best practice so to operate as to secure it. 

Treatment. — The treatment of a syncopal case of cerebral hemor- 
rhage is distinctly different from that of the congested or sthenic form, 
and as these two varieties of attack grade into each other, so must the 
practitioner in the treatment of individual cases alter and adapt his 
measures of relief. In either case it may be a matter of importance, 
as asserted by Bowles, to place the body in a semi-sitting position upon 
one side, to prevent the entrance of the secretions into the lungs, and 
also to lessen the danger of the falling back of the tongue and conse- 
quent interference with the respiration. In congestive apoplexy, with 
full, strong pulse, or small, wiry pulse, free venesection should be imme- 
diately practised ; the blood should be taken, with the patient in a sitting 
posture, from a large orifice in the vein, as rapidly as possible. The 
amount should vary with the case, but usually from one to one and a 
half pints may be abstracted, the flow being permitted until the pulse is 
distinctly softened. In very strong cases the lancet may be followed by 
a cautious administration of aconite to keep down any tendency to re- 
action, with its attendant rise of blood-pressure. In syncopal cases of 
apoplexy venesection does no good, and, in case the lesion be a throm- 
bus, may possibly do harm by increasing the tendency to clotting of 
the blood. It is especially in syncopal apoplexy that compressing the 
carotids, as recommended by Horsley and Spencer, might be tried. We 
can hardly conceive of a case in which the full operative procedure of 
tying the carotid with a ligature would be justifiable. 

In either form of apoplexy it is customary to attempt to control the 
hemorrhage by cold to the head — especially in the form of the ice-bag — 
and by sinapisms to the wrists, calves, and ankles, The efficiency of any 
of these means is extremely doubtful, but as they represent about all that 
can be done, and as it is usually essential, for the sake of those who are 
around the patient, to appear to be doing something, the treatment should 
be assiduously practised. In all cases of apoplexy a drastic cathartic 
should be given at once, partly because the symptoms are often aggra- 
vated by fsecal retention and partly because there is reason for believing 
that counter-irritation throughout the alimentary canal has some influ- 
ence in drawing blood from the brain. Of all the drastics croton oil is 
the most generally serviceable ; from one to two drops should be given in 
a tablespoonful of water, or be placed upon the tongue if there be diffi- 
culty in swallowing. 

Stimulants must be used in cases of apoplexy with the greatest reserve ; 
any drug which increases the arterial pressure certainly has in it great 
potentialities for harm, and it is doubtful whether a stimulant ever does 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 507 

any real good. A cerebral hemorrhage is not distinctly depressing to the 
heart or to the vital forces unless it be in overwhelming amount, and 
under any circumstance if the patient would die without stimulants it is 
almost certain he will die with them. Only when there can be no shadow 
of doubt as to the failing of the heart should stimulants be given. In 
all cases of severe apoplexy care should be exercised to prevent, if pos- 
sible, the formation of decubitus or acute trophic bed-sores. There is 
always danger that in the hurry and alarm of an apoplectic attack the 
patient may be severely injured by mustard plasters being allowed to 
remain on too long, and especially by being burnt with bottles of hot 
water, etc. In health warning sensations prevent accident ; in apoplexy 
they are absent. 

No drug will control the overpowering elevation of temperature which 
often occurs in mortal apoplexy, but in the slight fever of reaction aconite 
with antipyrin may be used with advantage. During this reactionary 
stage the patient, unless very feeble, should be kept for twenty-four or 
more hours without food, and then be given only milk or animal broths. 
It is often wise to administer frequent doses of calomel, whose purgative 
and antiphlogistic actions are alike beneficial. After recovery from the 
immediate effects of the apoplexy minute doses of corrosive sublimate 
(one seventy-fifth of a grain three times a day) or of potassium iodide 
(two grains) may be given continuously for some weeks, in the faint hope 
of aiding in the absorption of the clot. It is very uncertain how far these 
alteratives are sorbefacient, but in minute dose they are tonic rather 
than depressant and afford moral support. During this period the food 
of the patient should be light ; absolute freedom from excitement should 
be enjoined, and no mental effort whatever allowed. Laxatives are to 
be given freely. It is essential that neither strychnine nor electricity be 
used at this time. The gentlest massage may be allowed, and is often 
comforting. After from six to twelve weeks, however, electrical treat- 
ment may be employed, the faradic current being the one always se- 
lected, and the application being confined to the paralyzed muscles. 
The application of electricity to the head itself never does any good, 
and, if currents sufficiently strong to reach the brain be used, may do 
harm. The value of electricity at any stage of hemiplegia is very slight ; 
it has no effect upon the real lesion ; all that it can accomplish is to 
maintain the health of the muscles. As, however, the muscles, except 
in very rare cases, are in hemiplegia still under full trophic influence, 
the only tendency in them towards wasting is due to inaction, and there- 
fore develops very slowly. If in any case of hemiplegia which presents 
itself for treatment it is found that the muscles are soft and sluggish in 
their electrical reactions, distinct improvement under the use of electricity 
may be expected, for it is possible that at such time the amount of repair 
to the brain is greater than would appear from the symptoms, because 
the muscles themselves are out of health. The indefinite use of the faradic 



508 



DISEASES OF THE NEHVOUS SYSTEM. 



current in hemiplegia can at best only amuse the patient, and should be 
carried out, if at all, by an attendant, and not by the physician. Strych- 
nine is a classic remedy in hemiplegias. It has, however, no distinct 
specific action, but is useful simply by its tonic influences, or possibly 
in rare cases it may stimulate the motor ganglia of the cord when insen- 
sitive from want of use. 

In most cases there is a permanent loss of vital power and in the capa- 
bility for mental action after a cerebral hemorrhage, so that the patient 
requires habitually the use of measures tending to the building up of the 
general health, including abstinence from too much work. 

As death frequently occurs in apoplexy from arrest of respiration at a 
time when the circulatory forces are full of power, life may often be pro- 
longed by artificial respiration. We have seen the vigor of the heart 
maintained for hours after the total cessation of natural respiration, and 
when there is a minute hemorrhage into the medulla life may be saved 
by artificial respiration.* 

CEREBRAL PALSY OF CHILDREN. INFANTILE SPASTIC PARALYSIS. 

Definition.— Paralysis in children dependent upon organic brain- 
lesion, usually taking the form of a monoplegia or a hemiplegia, and asso- 
ciated with contractures and heightened reflexes. 

Etiology. — Cases which are here grouped together have as their 
starting-point various brain-lesions, which are followed in the course of 
years by pachymeningitis, scleroses, atrophies, and other secondary brain- 
changes, with consequent symptoms of palsy and irritation. The most 
frequent of all these primary causes is cerebral hemorrhage, which may 
occur before birth, is very often induced during hard labors, often by 
asphyxia or by the use of the forceps (usually meningeal, giving rise to 
sclerosis of the convolutions), or may happen at any time during early 
life. A cerebral hemorrhage very often in the child causes a convulsion, 
whilst a convulsion may induce a hemorrhage : so that cerebral paralysis 
in the child frequently dates from a convulsion or from the paroxysms of 
a whooping-cough. Porencephalia has been frequently found in autopsies 
upon old cases of infantile cerebral palsy. This lesion, first described by 
Henschl, consists in the presence of cortical cysts communicating with 
the arachnoid spaces and penetrating deeply into the brain, even as far 
as the ventricles. The nature of the primary attack in such cases is 

*In a case which H. C. Wood saw with Edward Martin, the symptoms were 
sudden unconsciousness and complete general muscular relaxation, followed in a little 
while by an entire arrest of respiration, accompanied by dropping of the tongue and 
jaw. Dr. Martin, being present at the moment of arrest of respiration, at once com- 
menced artificial respiration, and kept it up steadily for three-quarters of an hour, 
when attempts at breathing began. It was necessary, however, for nearly two days 
for an attendant to hold forward the jaw and tongue by raising the ramus of the jaw 
upward and forward, in order to prevent mechanical asphyxia by closing of the 
glottis. The final recovery was complete. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 509 

obscure. It may be, as suggested by Striimpell, that it is a polioen- 
cephalitis allied to poliomyelitis, but attacking the cerebral instead of 
the spinal cells. 

Symptomatology. — The symptoms of cerebral paralysis vary with 
the nature and the seat of the lesion. Idiocy, epilepsy, disorders of sen- 
sation, may be present in any degree of severity or may be altogether 
absent. Athetosis, choreic movements, tremors, nystagmus, often but 
not always accompany the paralysis. The latter is often hemiplegic, not 
rarely monoplegic, and in many cases is irregularly or symmetrically 
diplegic (i.e., on both sides of the body). If the diplegia attacks espe- 
cially the legs, a spastic paraplegia results, with its typical crossed-leg 
progression. 

The only symptoms which are common to all cases of infantile spastic 
paralysis are partial or more rarely complete paralysis, with marked 
contracture of the muscles, heightened reflexes, and preservation of the 
electro-contractility for a great length of time. 

Diagnosis. — The symptoms of spastic paralysis are so characteristic 
that there can usually be no difficulty in the diagnosis. The pseudo- 
rigidity of Osier, evidently a form of tetany, is at once distinguished by 
its development after prolonged illness, rickets, etc., and by the inter mit- 
tency and lack of permanency of the contractures. 

Treatment. — There is no specific medicinal treatment for spastic 
paralysis. The general health and nutrition of the child should be 
maintained in every possible way, and, when the local symptoms are not 
very severe, attempts should be made to lessen the disablement by mas- 
sage, by stretching, by passive movements, and by mechanical and sur- 
gical measures for the correction of deformities. In our opinion, surgical 
operations upon the brain itself are unjustifiable. 

DISEASES OF THE BRAIN. 

ACUTE HEMORRHAGIC ENCEPHALITIS. 

Definition. — An acute inflammation of the brain, attended with 
numerous minute hemorrhages. 

Etiology. — Acute hemorrhagic encephalitis appears to be always 
due to some primary infection. It has been especially noted in epidemic 
influenza, and has been recorded after cerebro-spinal meningitis and 
ulcerative endocarditis. 

Morbid Anatomy. — The lesion is usually localized. The part af- 
fected is swollen, extremely hyperteniic, and somewhat oedeinatous. The 
capillaries are intensely congested, and surrounded with microscopic 
hemorrhages and masses of exuded Avhite corpuscles. The nerve- ele- 
ments show evidences of rapid degeneration. 

Symptomatology. — In very acute cases, after one or two days of 
headache, giddiness, and malaise, stupor develops suddenly, and deepens 



510 



DISEASES OF THE NERVOUS SYSTEM. 



very rapidly into profound coma, with fixed pupils, rapid respiration and 
pulse, and ascending temperature, ending in death in forty- eight hours. 
In less severe cases the coma is less profound, and consciousness may 
return, when various focal symptoms, according to the seat of the lesion, 
may appear. 

Prognosis. — Death is the usual end of the stormy cases ; if conscious- 
ness return, recovery with more or less impairment of function may take 
place. 

Treatment. — In sthenic cases Oppenheim asserts that blood-letting 
with free after- use of calomel has been followed by recovery. In feeble 
cases cold may be used to the head and counter-irritation to the nape of 
the neck and to the lower extremities. 

Under the name of polioencephalitis superior there has been described 
by Gayet, Wernicke, and others a form of hemorrhagic encephalitis occur- 
ring mostly in chronic alcoholism, sometimes after influenza, and located 
in the neighborhood of the floor of the third and fourth ventricles and 
in the gray matter of the upper cervical cord. The prodromes, general 
symptoms, and course are similar to those of hemorrhagic encephalitis in 
general, except that the temperature remains near the norm, and paraly- 
sis of the eye- muscles appears early and rapidly deepens into a complete 
ophthalmoplegia, with in most cases an optic neuritis. A chronic form 
of the disease, with the eye-symptoms of the acute disease and with a 
disordered gait like cerebellar titubation, has been recorded. 

Hypertrophic Encephalitis. — In 1868, Hayem described under the name 
of sclerotic encephalitis a form of brain- inflammation which may be either 
diffused or localized, and which is characterized by swelling and discolora- 
tion of the part affected, accompanied by great engorgement of the blood- 
vessels, whose perivascular sheaths are also stuffed with leukocytes. 
Grasset believes this affection to represent simply a stage of hemorrhagic 
encephalitis, but in view of the cases recorded by Knags and Brown it 
appears probable that there is an encephalitis distinct from the hemor- 
rhagic variety, in which there is a subacute inflammatory increase of the 
neuroglia, with engorgement and dilatation of the perivascular spaces, 
ending in degeneration of the nerve- cells and atrophy of the tissues. In 
the majority of these cases there appears to be a history of traumatism. 
The symptoms during life have been prolonged apathy, deepening into a 
complete torpor of mind and body, loss of flesh, lowered temperature, 
irregular spastic contractions, and partial paralysis. There is no specific 
treatment. 

SUPPURATIVE ENCEPHALITIS. 

Definition. — A suppurative inflammation of the brain. 

Etiology. — Suppurative encephalitis may be of septic origin, and 
hence occurs as a secondary complication of various suppurative diseases. 
It also occurs after the various specific fevers, especially influenza. More 
frequently it is the result of a traumatism, or of the extension of inflam- 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 511 

mation from a neighboring part. As veins run directly from the brain 
over the petrous portion of the sphenoid, extension of inflammation by 
septic phlebitis may occur in suppurative otitis. A propagation of the 
disease-process through the lymphatics or by direct contact from the 
bone through the dura mater to the brain is, however, more common. 

Morbid Anatomy. — Suppurative encephalitis may exist with or 
without suppurative meningitis, and may be diffused or localized in soli- 
tary or multiple abscesses. The abscess may be with or without distinct 
capsule, according to its age, and may contain reddish- white or greenish 
pus, or in very old cases a yellowish, desiccated, caseous matter. In 
four -fifths of all cases the abscess is solitary. When it has followed 
sepsis or traumatism it is commonly situated in the frontal lobe and the 
centrum ovale ; when it is due to ear diseases it is usually either in the 
temporo-sphenoidal lobe or in the cerebellum. 

Symptomatology. — The brain-abscess, especially if situated in a 
frontal or lateral cerebellar lobe, may remain latent or give rise to simple 
headache and other obscure symptoms until it suddenly destroys life by 
bursting. Usually, however, violent headache, with vomiting, anxiety, 
mental confusion which in some cases amounts to an acute delirium, 
and general convulsions, are produced. If the abscess involve localizing 
centres, disorders of the pupil, of the movements of the eye, hemiplegic 
or monoplegic paralyses or spasms, disorders of the special senses, and 
other focal symptoms, may be present in accordance with the seat and 
the extent of the lesion. Owing to the increase of the pressure, optic 
neuritis almost always exists if the abscess is large. With these symp- 
toms is usually associated irregular fever, with chills and sweating. 

Diagnosis. — In the diagnosis of brain-abscess it is first important to 
recognize a sufficient cause. An abscess may follow an injury without 
there being any bone-lesion. The interval is usually from one to two 
weeks, but may be longer ; indeed, authentic fatal cases are on record in 
which the abscess did not manifest itself for years after the injury. In 
some cases of simple otitis media symptoms simulating meningitis and 
even abscess, such as headache, fever, and even double optic neuritis, 
are said to occur without abscess. Nevertheless, if persistent headache, 
with vomiting, and optic neuritis or other evidences of brain-pressure 
develop after a head-injury or during an otitis media or a septicaemia, the 
probabilities of the existence of a brain-abscess are so strong that they 
must be acted upon, unless reasons can be found for believing that there 
is a syphilitic or other form of brain-tumor. In such a case the occur- 
rence of chills, fever, and sweating would strongly corroborate the diag- 
nosis. It is a matter of great practical importance to locate the abscess. 
Abscesses in a frontal cerebral lobe and in a lateral lobe of the cerebellum 
produce no localizing symptoms ; this is also true of the temporal sphe- 
noidal lobes, a very common seat of abscess, unless the abscess be of suf- 
ficient size to involve the motor zone or the centres of speech. Disturb- 



512 



DISEASES OF THE NERVOUS SYSTEM. 



ance of equilibration in a case of brain- abscess points to the middle lobe 
of the cerebellum. 

Prognosis. — The prognosis in a case of brain-abscess which cannot 
be evacuated is absolutely fatal j recovery may occur under surgical 
treatment. 

Treatment. — In all cases in which the existence of a brain- abscess 
is probable, trephining should be at once resorted to. As the procedures 
to be adopted belong to surgery rather than to medicine, we shall not 
discuss them. 

HYDROCEPHALUS. 

Definition. — A condition of the brain characterized by accumula- 
tion of liquid in the ventricles.* 

Etiology. — Hydrocephalus may be primary or secondary, due to 
interference with circulation in the straight sinus or in the venae Galeni, 
or to stoppage of the foramen of Magendie or of Monro by exudation or 
tumor. Primary hydrocephalus may be congenital or developed shortly 
after birth. It is commonly connected with arrest of brain- develop- 
ment, but is in many cases similar in its origin to hydrocephalus of later 
life (so-called secondary), the difference being that it is not possible 
to demonstrate the original lesion in the grossly altered brain. The 
original causes of primary hydrocephalus are not known. 

Morbid Anatomy. — The ventricles are enormously distended with 
a colorless liquid (from a pint to eight quarts) containing mucin, fibrin, 
albumin, succinic acid, urea, cholesterin, etc. (Hilger.) The brain- 
substance is softened, cedeniatous, and thinned. The cranium may be 
very thin. 

Symptomatology. — The characteristic symptom of early hydroceph- 
alus is the enormous enlargement of the head, with distended fonta- 
nelles, prominent eyes (exophthalmos), and an, apparently, ludicrously 
small face. Great muscular weakness, imperfect intellection, nystagmus, 
paresis of the ocular muscles, contractures, epileptic attacks, and exag- 
gerations of the reflexes, are ordinary symptoms. 

Prognosis. — In congenital hydrocephalus death may be expected 
inside of four years, according to the severity of the symptoms. When 
disease develops after birth the case is more protracted, and may last 
into adult life. 

Diagnosis. — In rachitic macrocephalus the head is squarer than in 
hydrocephalus, and has a flattened vertex and non-bulging fontanelles. 
In simple cephalic hypertrophy the enlargement is chiefly occipital, in 
hydrocephalus it is chiefly frontal. 

Treatment. — Eepeated minute tappings of the ventricle, with grad- 



* Hydrocephalus as here denned is the hydrocephalus internus of authors : in 
cerebral atrophy fluid may accumulate between the dura and the pia mater, consti- 
tuting the hydrocephalus externus of authors. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 513 

ual compression by means of broad straps of adhesive plaster, are gen- 
erally used, but it is doubtful whether surgical interference ever does 
any good. The wisest course is to struggle only for euthanasia. 

ACUTE PERIENCEPHALITIS. 

Definition. — An acute disease of the brain, attended by stupor, wild 
delirium, general disturbances of the psychic functions and of the motor 
functions, and fever ; dependent upon acute hyperemia and subsequent 
inflammatory changes in the cerebral cortex. 

Synonymes. — Acute peripheral encephalitis ; Phrenitis mania gravis ; 
Typhomania ; Acute delirium ; Delirium grave ; Bell's disease (Luther 
Bell). 

Etiology. — Idiopathic non-septic periencephalitis may be produced 
by profound grief, protracted anxiety, especially when accompanied by 
great overwork, partial starvation combined with the gnawing anxiety 
of deep poverty, and also, it is affirmed, by sunstroke. It certainly may 
develop without apparent cause during locomotor ataxia, or may occur 
as an exacerbation of chronic periencephalitis. It is especially frequent 
during pregnancy following seduction ; and the cases of death from 
alleged acute hysteria which have taken place after rape and various 
intense emotional disturbances have probably been instances of the dis- 
order. Those cases of acute periencephalitis which have been reported 
as produced by acute fevers, traumatism, and various purulent diseases 
were evidently of septic origin. 

Morbid Anatomy. — The lesion of acute periencephalitis is an acute 
inflammation, solely or chiefly confined to the cerebral cortex and its 
membranes, and first appearing as an excessive hyperemia, which is 
rapidly followed by escape of the white blood- corpuscles and filling up 
of the lymph- spaces both of the pia mater and of the cortex by leukocytes, 
which finally invade also the periganglionic spaces. Not rarely the whole 
cortex is oedematous, and minute apoplectic hemorrhages may occur. As 
to the ultimate nature of the inflammation and its cause there has been 
much discussion, but it seems certain that periencephalitis may be of 
various origin. It may be septic, as it has occurred in septic subjects, 
and as various forms of pyogenic organisms have been detected in the 
inflamed tissues by Braden Kyle, James E. Hunt, and others. Easori 
affirms that he has isolated from a case of periencephalitis a hitherto 
undescribed bacterium, which injected into rabbits produced septicemic 
death. On the other hand, periencephalitis may exist without the pres- 
ence of any micro-organisms in the brain or the general system. It 
would appear, therefore, that the existence of two varieties must be 
recognized (with the possibility of a third) : first, septic periencephalitis ; 
second, idiopathic periencephalitis, produced by emotional causes ; third, 
and at present very doubtfully, a bacterial periencephalitis, due to a 
peculiar specific organism. 

33 



514 



DISEASES OF THE NERVOUS SYSTEM. 



Symptomatology. — The onset of acute periencephalitis may be 
abrupt, but usually there are some prodromes, such as short periods of 
impaired consciousness, especially upon waking in the morning, or brief 
nocturnal attacks of wandering delirious restlessness, or mental excite- 
ment, or pronounced mental aberration. We have seen during the day 
a patient warn those about him that he would kill them during the 
night in his period of delirium. A complete insomnia rapidly develops, 
and soon the delirium becomes constant : the night and the day are 
passed in violent excitement, with a perpetual outpouring of incoherent 
speech and a fury of fighting and destructiveness. 

Hallucinations and half- formed delusions are present, and often bear a 
close relation to the cause of the attack. The abandoned mistress will in 
her ravings recount her past shame and present agony. The business- man 
will be perpetually occupied with an incoherent jumble of business trans- 
actions. Almost invariably along with the delirium there is great phys- 
ical restlessness, which grows more intense until it causes the patient to 
leap from his bed and to attempt to run away. Very commonly violent 
assaults are made upon the attendants. Convulsions are rare. The de- 
lirium may at first be not continuous, occurring only at night, or at least 
be interrupted by brief intervals of comparative rationality during the 
daytime. Finally, however, there is persistent intense mania. 

During the whole course of the disease the pulse is rapid ; if in the 
beginning it possesses a show of force it is in fact soft and compressible. 
Food is usually absolutely refused. The fever is pronounced, and the 
temperature may reach 106° F. According to our observations, the tem- 
perature varies with a stormy irregularity which is almost characteristic, 
rising and falling many degrees many times during the twenty-four hours. 
Its variations are connected with the mental and physical excitement of 
the patient, maniacal outbursts producing an immediate rise of the tem- 
perature. In advanced stages the temperature may fall much below the 
norm. The pupils may be contracted, dilated, or normal. In the course 
of a few hours to several days the second stage of the disorder develops. 
There are now quiet coma or else muttering delirious unconsciousness, 
failing pulse, cool skin, and general evidences of collapse. In the early 
part of this stage, when aroused, the patient may respond incoherently 
or perhaps give some slight evidences of comprehending what is said 
to him, but he rapidly sinks lower and lower until he dies from exhaus- 
tion. Early in the disorder the skin becomes very harsh, and finally cya- 
notic ; in the later stages irregular desquamation, or even ulceration, may 
occur. In a case quoted by Spitzka the anaesthesia was so complete that 
the patient gnawed off a portion of one of his fingers. Pemphigus-like 
vesicles, phlegmons, decubitus, gangrenous patches of skin, or gangrenous 
extremities are occasional complications. 

Diagnosis.— As it is probable that acute mania and acute perienceph- 
alitis simply represent different degrees of one disease, it is apparent that 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 515 

the diagnosis between the two disorders may be not only difficult bnt 
impossible. The points upon which such diagnosis rests are the greater 
intensity of the symptoms and especially the presence of pronounced 
fever in acute periencephalitis. Ordinarily in acute mania the bodily 
temperature does not rise more than a degree above the norm, and Krafft- 
Ebrng affirms that in a maniacal case the temperature of 100.5° F. indi- 
cates strongly delirium acutum. H. C. Wood, however, has shown that 
there exists every grade of temperature in maniacal cases, so that no 
sharp line can be drawn, either as regards the intensity of the symp- 
toms or the height of temperature, separating clinically the two alleged 
diseases. Again, an acute periencephalitis may be with great difficulty 
separated from an acute confusional insanity, in which violent delirium 
with irregular fever and the rapid development of typhoid symptoms 
make a picture which cannot be at once distinguished from that offered 
by acute delirium. Even in the most acute form of confusional insanity, 
however, there are usually in the first days of the attack some of the pecu- 
liar confusion, the excess of hallucinations, or other symptoms that mark 
confusional insanity. The diagnostic difficulties are farther intensified by 
the circumstance that the causes which produce a confusional insanity 
in one case may be apparently the same as those which cause acute peri- 
encephalitis in another. Thus, the so-called puerperal insanity, which is 
commonly spoken of as though it were one form of disease, may be a vio- 
lent confusional insanity, or it may be a septic periencephalitis, or it may 
be a non -septic idiopathic periencephalitis. 

Carelessness on the part of the practitioner may lead to a sympto- 
matic delirium being considered as acute delirium. This is especially 
true of the abrupt maniacal outburst which occurs in latent pneumonia. 
Such outburst, however, almost without exception takes place in young 
children or in persons broken down by age or by excessive privation or 
dissipation, so that the character of the subject should put the practi- 
tioner on his gaard, and physical examination would reveal at least 
pulmonic percussion dulness. 

Prognosis. — The prognosis of acute periencephalitis is highly un- 
favorable ; at least three-fourths of the cases end fatally. When recovery 
occurs the mind is almost invariably left in a damaged state. The more 
violent the symptoms the worse the outlook. 

Treatment. — The early symptoms and the lesions of acute peri- 
encephalitis suggest venesection and local blood-letting as a means of 
resisting the disease. It may be that in some cases of the disorder these 
measures are indicated, but we have never met with such a case. As 
the affection is ordinarily seen, the antiphlogistic treatment must be lim- 
ited to the local application of cold to the head, to the use of blisters, and 
to the administration of drastic purgatives. Hyoscine hydrobromate 
should be given in full doses every six hours (one seventy-fifth of a 
grain) until physiological effects are apparent. With it, in many cases, 



516 



DISEASES OF THE NERVOUS SYSTEM. 



can be advantageously combined morphine or chloral. Solivetti asserts 
that he has obtained extraordinary results from hypodermic injections 
every eight hours of one gramme of ergotin. Certainly the use of ergot 
would seem to be indicated, and the severity of the disorder thoroughly 
justifies the risk of any local trouble from hypodermics. A filtered solu- 
tion of the official extract of ergot in freshly boiled water may be used, 
ten grains every three hours. In the later stages of the disorder alco- 
holic and cardiac stimulants may be employed pro re nata. 

During the whole course of the disease it is essential that the restraint 
which is usually necessary be applied in such a way as not to increase the 
excitement. ~No one should be allowed in the room except the nurses. 
Non- irritating nutritious foods must be administered in as large amount 
as possible : milk, raw eggs, strong animal broths and essences, thickened 
soups and such liquid foods, are to be employed, and in many cases must 
be given with the stomach-tube. 

CHRONIC PERIENCEPHALITIS. 

Definition. — A chronic disease, dependent upon a peculiar inflam- 
matory degeneration of the cerebral cortex, which gives rise to change of 
character, progressive mental deterioration, with delusions of grandeur, 
emotional exaltation or emotional depression, occasional maniacal out- 
breaks, and epileptic attacks, with progressive physical deterioration, 
as shown by irregularity of the pupils, disorder of speech, and loss 
of control over the movements of the hands and legs, — all symptoms 
finally being swallowed up in a complete paralysis of intellection and 
of voluntary motion. 

Synonym ks. — Paretic dementia; General paralysis of the insane; 
Paresis ; Dementia paralytica ; Periencephalo- meningitis. 

Etiology. — General paralysis is not a distinctly hereditary disease, 
is rare in females, and is remarkably frequent in military and naval 
officers. In civil life the disease is most frequent between forty and 
fifty years of age, and very rare under thirty or over sixty. According 
to Mickle, in soldiers and sailors the average age is about thirty-three. 
These peculiarities, however, are probably simply the outcome of differ- 
ences in the degrees of exposure to the great causes of the disorder, which 
are alcoholic and sexual excesses, syphilis, and a long- continued emo- 
tional strain, such as that of excessive ambition or excessive anxiety, 
factors whose influence is increased by overwork. According to Mendel, 
seventy -five per cent, of the cases of general paralysis have a distinct 
history of syphilis, whilst in other insanity the percentage is about 
eighteen. As the disease is not gummous, — i.e., specifically syphilitic, 
— it is evident that the relations between it and syphilis are parallel to 
those which exist between locomotor ataxia and syphilis. It is a post- 
syphilitic affection. It also occurs not rarely as a late complication in 
locomotor ataxia, and locomotor ataxia or other spinal sclerosis frequently 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 517 

develops in the paralytic dement. Sunstroke and traumatisms are as- 
serted by authorities, with doubtful correctness, to be among the exciting 
causes of periencephalitis. 

Morbid Anatomy. — Various secondary or complicating alterations 
of the skull, the brain, and its membranes are found in old cases of 
periencephalitis. The characteristic lesions are, however, in the cerebral 
cortex, which is usually discolored, sometimes firmer, sometimes softer, 
than normal, often containing minute cysts varying in size from that of 
a pin's point to that of a millet-seed. Microscopic examination reveals 
degeneration or perhaps complete disappearance of the ganglionic cells 
and a peculiar alteration of the white fibres, which renders them much 
more apparent than in the healthy brain, besides pronounced degenera- 
tion of the neuroglia and large numbers of peculiar many-processed con- 
nective-tissue cells (Deiters's or spider-shaped cells). The blood-vessels 
are usually injected, and altered in character, with distention of the adven- 
titial lymph- spaces. The spinal cord is very frequently degenerated. 
Changes in the sympathetic ganglia have also been noted by recent 
investigators. 

In regard to the original nature of the changes which have just been^ 
described, there are two distinct views held by alienists : the one which 
seems to us most probable is that the disease is a diffused interstitial 
cortical encephalitis, in which the connective tissue and the blood- 
vessels are primarily affected. In accordance with the second view, 
however, the process is a diffused parenchymatous inflammation, which 
begins in the nerve-elements and secondarily involves the neurogliar 
tissue. 

Symptomatology.— For the purposes of discussion we shall recognize 
the four stages commonly made by writers on General Paralysis ; but it 
must be understood that these stages in their time-relations vary almost 
indefinitely, and that in many cases some of them never appear, or at 
least are so very brief and indistinct that they pass unobserved. 

The symptoms of the prodromic stage of chronic periencephalitis 
may be indistinguishable from those of an ordinary cerebral neurasthenia, 
consisting of loss of power of fixing the attention, apathy, inability for 
mental exertion, and some emotional depression. If to these symptoms 
be added distinct vaso-motor phenomena, such as facial congestion, head- 
ache, vertigo, tinnitus aurium, temporary hemianopsia and other dis- 
turbances of vision, and a slight alteration in the character of the patient, 
there is sufficient ground for fear. Krafft-Ebing gives as almost char- 
acteristic the peculiar alteration of the relations of the patient to time 
and space, which renders him exceedingly unpunctual or causes him at 
times confusedly to lose himself in well-known streets. Although this 
stage is so often overlooked, yet after the disease has declared itself the 
books and correspondence of the business-man or the office-histories and 
records of the professional laborer will, in their loss of accuracy and 



518 



DISEASES OF THE NERVOUS SYSTEM. 



dignity and in their general evidences of failing power, usually afford a 
history of a slowly progressive mental degeneration. 

In the second stage the mental aberration is pronounced and distinct, 
but the motor disturbances of the more advanced disorder are wanting. 
This stage of the disease is usually short, but we have seen it persist for 
more than a year without the slightest failure of the general physical 
powers. 

The third stage of the disease is that in which the motor symptoms 
become marked, as shown in inequality of the pupils, flabbiness and loss 
of expression of the face, disorders of articulation, general loss of en- 
durance, and, it may be, distinct paresis of the extremities. 

The fourth stage of the disease is that in which the dementia is com- 
plete and the general loss of muscular power very great, the patient 
being reduced to a feeble automaton. 

The mental phenomena of paretic dementia may be considered for the 
purposes of study as conforming with four types, but every grade of 
cases exists between these types, and the same individual cases may at 
different periods represent two or more of them. In the first form of 
^paretic dementia (vulgo, softening of the brain) there are no marked emo- 
tional disturbances or delusions, but simply a progressive failure of the 
mental and physical faculties, which ends after a period of childishness 
in complete dementia. In the second form of the disease there are delu- 
sions of grandeur or expansive delirium ; these delusions may be of the 
most intensely dominating character or so mild that they may be readily 
overlooked ; they may be replaced by simple emotional exaltation, so 
that the man is not affected by any depressing circumstances or surround- 
ings, although he may make no assertions of the possession of high facul- 
ties or of great power or wealth. Such cases as these may be considered 
as midway between the first and second types. Maniacal outbursts may 
occur in any form of paresis, but are especially frequent when there are 
delusions of grandeur. 

The third form of general paralysis is that in which there is emotional 
depression and even pronounced melancholia with depressive delusions. 
Not rarely the depressive delusion relates to the person of the patient, 
who believes himself ill, deformed, or wanting in some member or func- 
tion. In this way arises the so-called hypochondriacal variety of general 
paralysis. 

The fourth and rarest form of general paralysis is that in which ex- 
citement and depression alternate so as to make a periodic or circular in- 
sanity. The excitement and depression may abruptly succeed each other, 
but in some cases are separated by a lucid interval, so that the whole 
cycle will consist of three periods. According to Mickle, such a cycle 
differs from that of ordinary circular insanity in the order of sequence, 
which is — first, excitement ; second, calm ; third, depression. 

Major and minor epileptiform convulsions may usher in a general 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 519 

paralysis or may occur at any time during its course. The seizure may 
consist of a sudden pallor with mental confusion, or of a momentary 
unconsciousness, or of a dilatation of the pupils with drawing of the 
head, or of a sudden fixation of the countenance with an outpouring of 
cold perspiration, or of an automatic repetition of coherent or incoherent 
phrases. Such an attack occurring in persons who have been subject to 
the causes of a general paralysis and are of the proper age should always 
excite alarm. 

Not rarely epilepsy in general paralysis takes upon itself the Jack- 
sonian form, the convulsion being limited to isolated groups of muscles, or 
to one side of the face, one leg, or one arm, or being hemiplegic. Usually 
the attack begins with an aura, which is especially apt to be vertiginous. 
Sometimes the convulsion is preceded for several days by excessive rest- 
lessness, tinnitus aurium, and great psychical excitation. In other cases 
it begins with vomiting. In the advanced disease epileptic fits may be 
frequent and severe, and the observation of Esquirol that a succession 
of them frequently closes the scene has received abundant confirmation. 
When the true epileptic status occurs during a general paralysis the suc- 
cessive convulsions are often very diverse, one being complete, the next 
partial, — in one the head being drawn to the right, in the next to the left, 
and so on. After the paroxysms, convulsive tremblings frequently per- 
sist in single muscles or in groups of muscles for many hours, and are 
followed by a more or less pronounced partial palsy. To use the words 
of Mchol, paralysis follows the convulsion or spasm as the shadow 
follows the body. During the more severe paroxysms consciousness is 
always lost, but in mild attacks, and especially wheu the convulsive 
movements are more or less local, it may be perfectly maintained ; occa- 
sionally it is affected as in hysteria. Sometimes the convulsion may be 
replaced by an apoplectiform attack. The mental condition of the patient 
is almost always distinctly worse after a severe seizure. 

The most characteristic motor symptom of chronic periencephalitis 
is an incomplete paralysis affecting all the body and commencing with 
tremors and disorders of coordination. The first manifestation is usually 
a loss of control over complicated muscular movements of the hands, so 
that a man although able to lift many pounds may not be able to write 
his name. In engravers or other persons whose daily vocation requires 
great technical hand-skill this loss of muscular control may be the first 
distinct evidence of a general paralysis. 

Inequality of the pupil in the early stage of the disorder is a not un- 
common, and in the later stage is a constant, phenomenon. It may be 
associated with mydriasis or myosis. A similar loss of delicacy of move- 
ments in the lips and tongue produces in general paralysis a difficulty of 
pronunciation, which is especially manifested in the speaking of the lin- 
gual and labial consonants and in the syllables of long words. Moreover, 
as mental power fails there is a corresponding failure in the formation 



520 



DISEASES OF THE NERVOUS SYSTEM. 



of ideas and of the association of the ideas with the spoken words. 
Through the failure of mind and of tongue there arises a peculiar stut- 
tering or hesitating, somewhat thick, characteristic speech. There is 
often an elision of syllables, a dropping out of words, and a marked 
tendency to fall into a rhythmical speech, giving rise to a peculiar utter- 
ance like that of a school-boy scanning Latin poetry, and hence it is 
spoken of as " scanning speech." 

The handwriting in general paralysis very early becomes shaky and 
irregular, with ill-formed, widely separated lines, and often with a dis- 
appearance of the finely graded strokes of correct writing in a common, 
thick, uncertain line. The mental characteristics of the disorder show 
in the writing as much as in the speech. The dropping out of letters, 
the omission or repetition of syllables, and the elision or interjection of 
words and clauses, are almost characteristic. In medico-legal cases letters 
often afford most effective testimony. 

In periencephalitis there is neither headache nor pain, save as a com- 
plication, such as may occur from the development of locomotor ataxia, 
etc. In the advanced stages increasing numbness passing into analgesia 
is almost invariable, making it especially necessary to provide carefully 
against possible accidents to the patient. We have known such a patient 
scalded to death by getting into a too hot bath. 

Violent sexual excitement is often one of the earliest symptoms of 
general paralysis, but in the progress of the disease it gradually gives way 
to impotence, excessive libidinousness often persisting after the total loss 
of sexual power. 

Disturbances of temperature, especially a tendency to an evening rise 
and to irregular paroxysmal alterations of temperature without apparent 
cause, are very frequent in general paralysis. Especially characteristic is 
a liability to the production of violent fever by very slight cause. The 
epileptic paroxysm may occur without alteration of temperature, but is 
usually accompanied by a distinct rise, which frequently precedes by eight 
or ten hours the convulsion and lasts many hours after it. Both Mendel 
and Westphal have recorded cases in which a continuing epilepsy was fol- 
lowed by a violent fall of temperature. Usually, however, a decided fall 
of temperature in an attack of unconsciousness marks the occurrence 
of a true apoplexy. In advanced dementia the temperature is commonly 
subnormal, and often different upon the two sides of the body. 

Diagnosis. — Although it may not be possible to make a positive diag- 
nosis in the prodromic stage of general paralysis, the recognition of the 
probable nature of the attack may be of supreme importance for the 
good of the patient and of his estate. Sudden changes of character, ac- 
companied by a tendency to sexual crimes, or to the formation of large 
plans beyond the means of the patient, or to excessive expenditure of 
money, if occurring in a man of middle age with a history of past 
syphilis, or of abuse of alcohol, or of excessive mental or emotional work, 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 521 

should be sufficient ground for practical action, especially if they be asso- 
ciated with great hilarity, bien-etre, or emotional or mental exaltation. 

The diagnosis between paretic dementia and syphilitic cortical disease 
is frequently not possible in the beginning of the attack. The occurrence, 
however, of headache or of localized palsies points strongly to syphilis. 
(See page 530.) When the mental disorder precedes, as it occasionally 
does, for several years the distinct physical symptoms, the diagnosis is 
between a dementia paralytica and a pure insanity. Very often in these 
cases either irregularity of the pupil or loss of power of executing fine 
movements, such as those of writing, buttoning, dancing, etc., can be 
detected if the case is one of periencephalitis. Of almost equal impor- 
tance is a distinct and progressive failure of memory, which is not a 
feature of the earlier stages of the pure insanities. 

Prognosis. — Usually death occurs in general paralysis in from two to 
three years. Cases lasting four years are not extraordinary, whilst some 
have passed the decennium. Very acute cases may terminate in three or 
four months. The prognosis is always bad. It is probable that in those 
cases in which recovery is claimed the diagnosis was at fault. 

Treatment. —From the despairing outlook of general paralysis it is 
justifiable in the beginning of an attack to use local blood-letting by 
leeches, the actual cautery, and other counter-irritations to the nape of 
the neck. Especially should this be done if apparently cortical disease 
has followed traumatism or sunstroke and is therefore in all probability 
largely meningeal. 

As the early diagnosis between this disease and syphilis of the brain 
is often not possible, acute antisyphilitic medication in many cases should 
be essayed. Eestraint is in the early acute stages of the disease always 
necessary, and usually very difficult of enforcement outside of an asylum. 
Very good results in obtaining remissions have been claimed by alienists 
from the employment of massive doses of ergot. One to two drachms a 
day of the official extract should be given continually for weeks, unless 
coldness of the surface or other physiological effects become apparent. 
Hyoscine, morphine, and sulphonal are useful for overcoming wakeful- 
ness or excitement. Massage, moderate bathing, very carefully restricted 
out-door exercise, very warm clothing, a non- stimulating but abundant 
and nutritious diet, the avoidance of physical and mental as well as emo- 
tional excitement, and in the later stages of the disease great care to pro- 
tect the patient from his fecal and urinary discharges and to prevent 
decubitus, constitute in outline the measures to be employed. As fatal 
pneumonia has frequently been produced in the advanced stages by par- 
ticles of food getting into the lungs, a liquid or semi-liquid diet should 
be given. 

DISSEMINATED SCLEROSIS. 

Definition. — A disease whose essential lesion is nodules or patches 
of sclerotic tissue scattered through the nerve-centres. 



522 



DISEASES OF THE NERVOUS SYSTEM. 



Synonymes. — Multiple sclerosis ; Multiple cerebro-spinal sclerosis. 

Etiology. — In the great majority of cases no cause can be assigned. 
Barely have several members of one family been affected, and it is af- 
firmed that the disease is sometimes a sequela of exanthematous fever. 
The subjects may be of any age, but the period of life most liable to 
attack is from forty to sixty. 

Morbid Anatomy. — The diseased areas are irregular, from two to 
thirty millimetres in diameter, on exposure to the air reddish gray (in the 
brain) to grayish white (in the spinal cord), very firm, consisting of con- 
nective tissue, free from nerve- elements, or more commonly containing 
axis- cylinders deprived of their medullary sheaths. The blood-vessels 
are usually sclerotic, but may be fatty. Any portion of the nerve-centres 
may be the seat of nodules, which may even form in nerve-roots, and 
have been especially noted in the optic or other nerves of special sense. 
The white matter is usually involved to a greater extent than is the gray. 

The patches may exist either in the brain or in the spinal cord alone, 
or, as in the ordinary type, may be cerebro-spinal. The development of 
the lesion appears to be — first, increase of the neuroglia, with multipli- 
cation and enlargement of the nuclei ; then atrophy of the medullary 
sheaths, with preservation or even augmented volume of the axis- cylin- 
ders ; finally, atrophy of the latter. According to Charcot, the long per- 
sistence of the axis- cylinder is characteristic of this form of sclerosis, 
distinguishing it from that which involves nerve-tracts. Taylor asserts 
that the ganglionic cells are often deeply pigmented when the nodule is 
situated in the gray matter. 

Symptomatology. — In the great majority of cases disseminated scle- 
rosis is very insidious in its onset and progress. The chief symptoms 
are a very slowly increasing loss of memory and of general mental and 
physical power, with vertigo, volitional tremors, defects of speech, vari- 
ous eye-symptoms, and minor nerve- disturbances, according to the seat 
of the lesion. 

The characteristic of the volitional tremor is its cessation during com- 
plete rest, such as is obtained by absolute repose and support of every 
part of the body when lying down. The oscillations are commonly ex- 
tensive, rhythmical, and slow, from seven to ten per minute ; they are 
especially pronounced in, but are not confined to, the part which is in 
action. They usually develoj) first in the hands, and for a time may exist 
solely in the upper extremities. The head is early attacked. 

The eye-symptoms are squint, with its consequent diplopia ; various 
irregularities of the pupils ; nystagmus, the movements being usually 
horizontal, in rare cases vertical ; inability to move the eyeballs in unison ; 
and atrophy of the optic nerve, with amblyopia, dyschromatopsia, con- 
traction of field, scotomata, transitory attacks of blindness, etc. 

The defects of speech vary : there may be simple tremulousness, or 
thickness of utterance, or scanning speech like that of general paresis. 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 523 

The vertigo is a constant and often severe symptom, and is usually a 
true whirling vertigo ; in the advanced stages to it may be added the 
giddiness of diplopia. 

The mental disturbance may be simply a loss of power, but there 
may be delirium of grandeur and hallucinations 5 melancholia, hypo- 
chondriasis, or almost any of the forms of pure insanity, so called, may 
be simulated. 

Paresis, spasmodic contractions, spastic paralysis, muscular atrophies, 
diminished or excited reflexes, various disturbances of sensation, girdle- 
pains, fulgurant pains, as of locomotor ataxia, disturbances of coordi- 
nation, in a word, any of the symptoms which are producible by sclerotic 
disease of the spinal cord, may be present, according to the position of 
the nodules in the cord. Even cerebellar titubation is said to have been 
noted in cases in which the middle lobe of the cerebellum was especially 
affected. 

Apoplectic seizures and epileptic attacks are common, and may end 
in death ; not rarely they are followed by a hemiplegia in which the 
muscles are flaccid, rarely contracted. The hemiplegia may be accom- 
panied by aphasia or by crossed or direct facial palsy, but passes off in 
a few days. If death occur in an apoplectic attack, no relation between 
the symptoms and the lesions can usually be made out. 

Diagnosis. — The diagnosis of a typical case of multiple sclerosis is 
very easy ; in children, however, it may be confounded with Friedreich's 
ataxia, from which it should be immediately separated by the volitional 
tremor. The tremors appear to be of cerebral origin, and with the mental 
symptoms are absent when the nodules are confined to the spinal cord. 
The symptoms of such a purely spinal multiple sclerosis differ from those 
of a sclerosis affecting certain tracts, in that they do not conform with the 
function of any one tract. Thus, fulgurant pains may coexist with in- 
creased patella reflexes, because of the sclerotic degeneration being pres- 
ent both in the posterior and in the lateral regions ; or the knee-jerks may 
be different in the two sides of the body ; or atrophy may exist in certain 
muscles, with evidences of spastic paralysis in other muscles, and ful- 
gurant pains in other parts, showing the coexistence of scattered lesions 
in the lateral, posterior, and central portions of the spinal cord. In 
spinal cases the diagnosis must rest upon the slowness of development 
and the demonstration by the diversity of the symptoms that there are 
multiple lesions. 

Prognosis. — The course of multiple sclerosis is essentially slow, many 
years usually being required for the complete development of the dis- 
order. It is affirmed by authorities that a small proportion of the cases 
recover, but we are inclined to believe that such cases have been instances 
of mistaken diagnosis. 

Trkatm fat.— Zinc phosphide and the double gold and sodium chlo- 
ride have been recommended by various authorities and may be used. 



524 



DISEASES OF THE NERVOUS SYSTEM. 



Arsenic, belladonna, ergot, the whole line of the spinal sedatives, have 
also been lauded from time to time, but there is no sufficient reason for 
believing that they have value. Strychnine, it is stated, will sometimes 
arrest temporarily the tremor, but it seems probable that its general in- 
fluence would be for harm rather than for good. Solanine, according to 
Grasset, in the dose of one and a half to two grains a day will distinctly 
lessen the tremor, and we have found hyoscine sometimes to have such 
action. Massage, electrical treatment, douches, and suspension may all 
be tried, as in other forms of spinal sclerosis. 

INTRA-CRANIAL TUMORS. 

Definition. — New formations within the brain. 

Etiology. — The causes of brain-tumors are the same as those of neo- 
plasms situated in other parts of the body. 

Morbid Anatomy. — The varieties of brain-tumor are Glioma, Syphi- 
loma, Sarcoma, Solitary Tubercle, Carcinoma, Fibroma, and Cystic Dis- 
ease of the Choroid Plexus, with, as rare phenomena, Lipoma, Psam- 
moma, Cholesteatoma, Osteosarcoma, Dermoid and Echinococcus Cysts, 
and almost all other known varieties of morbid growth. Of these tumors 
the syphiloma is the most common ; next to it in frequency come in 
adults the glioma, gumma, or sarcoma, in children the solitary tubercle. 
The glioma is found especially in the cerebral hemispheres and the cere- 
bellum ; the tubercle affects chiefly the pons, the cerebellum, and the 
cerebral cortex. The sarcoma, glioma, and tubercle are capable of quick 
development, but often grow slowly, and may remain stationary for an 
almost indefinite period. By direct pressure and irritation, and espe- 
cially by interfering with large blood-vessels, tumors give rise to second- 
ary changes in the brain-tissue which may involve distant parts and 
produce localizing symptoms which draw attention away from the original 
lesions and lead to mistaken diagnosis as to the seat of the tumor. By 
direct pressure upon the skull tumors situated in the outer parts of the 
cerebrum may lead to softening of the skull (craniotabes), or even to com- 
plete perforation (osteoporosis). In rare cases deeply seated tumors not 
in contact with the bone bring about similar changes. 

Symptomatology. — The symptoms of brain-tumors may be divided 
into general — i.e., those which evince simply a general cerebral disturb- 
ance — and focal, — i.e., those which are dependent upon disorders of func- 
tion caused by the local action of the tumor. 

The general symptoms are headache, vomiting, stupidity, giddiness, 
slowing of pulse, and optic neuritis. Of all these symptoms headache is 
the most rarely absent. It is usually intense, unyielding to remedies, 
constant, with paroxysmal exacerbations, especially at night, and inten- 
sified by jarring, straining, coughing, or other acts increasing the blood- 
pressure. It may be localized in the region of the tumor, but usually it 
is diffuse. The apathy or stupidity is most marked in advanced stages of 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 525 

tumor, but may be an early symptom. It often gives rise to a peculiar 
slowness and hesitancy in speech and in act, and may be accompanied by 
pronounced somnolence, which in turn may pass into profound coma. 
Distinct mental aberration, with hallucinations, may occur in brain- 
tumor, but is rare. On the other hand, failure of memory and of the 
other mental powers is common. 

Vomiting is often absent, but may be the first symptom. It is espe- 
cially severe when the cerebellum is involved. The attacks come on 
without apparent cause, and without connection with the taking of the 
food. The nausea is not pronounced. Optic neuritis is present in nearly 
ninety per cent, of the cases j it is usually double. As time goes by, a 
very pronounced choked disk commonly gives way to atrophy of the 
nerve. 

Except in cerebellar tumors, giddiness rarely amounts to a violent 
vertigo or to such a disturbance of coordination that the subject is 
forced to lie down to prevent falling. It is especially apt to come on 
when the patient suddenly rises from the supine position, or when acts 
are performed which increase greatly the blood-pressure. It often occurs 
with vomiting in the acme of a cephalalgic exacerbation. 

Epileptic attacks may take the form of petit rnal, but are usually 
accompanied by a general, often very severe, convulsion. True epileptic 
automatism or destructive mania is very rare, if it ever occurs. When 
the tumor is in the motor zone the fit usually begins in, and often is con- 
fined to, one extremity (Jacksonian epilepsy). An aura may precede an 
organic convulsion when a special centre is involved. The aura usually 
consists of a corresponding subjective sensation. 

Slowing of the pulse (to even forty per minute) is especially present 
when the tumor irritates the pneumogastric nucleus, but is often pro- 
duced by the general brain-pressure. 

Fever may be present in brain-tumor, especially when growth is rapid 
or the pons is involved, and the local temperature over the tumor may be 
higher than in the corresponding position on the other side of the head. 
According to Bruns, a peculiar bruit may be sometimes heard over the 
tumor. 

The focal symptoms of brain-tumors vary in accordance with the seat 
of the tumor, and are so closely in accordance with the rules before 
enunciated (page 471) that it appears to be a work of supererogation to 
enter here upon their discussion. Nevertheless, certain brief statements 
seem justifiable. 

Anterior Lobes. — There are no localizing symptoms, unless the olfactory 
bulbs are involved, as is especially the case in glioma, when subjective 
sensations of smell become prominent phenomena, and in advanced stages 
may be associated with more or less complete loss of the sense. 

Psycho-motor Area. — Tumors are especially connected with local, 1110110- 
plegic, or hemiplegic spasms or paralyses, and with Jacksonian epilepsy. 



526 



DISEASES OF THE NERVOUS SYSTEM. 



Commonly the local spasms are attended with tingling and with numb- 
ness, and it is especially important to observe in any case the exact 
locality at which this sensory disturbance first manifests itself, as it usu- 
ally is more confined in its distribution than is the spasm, and therefore 
more closely represents the part of the psycho- motor area involved in the 
lesion ; if there be remaining temporary paralysis, its position should 
correspond to that of the numbness. Aphasia is a localizing symptom, 
but when it occurs in paroxysms it indicates that the centres are rather 
indirectly than directly involved. 

Parietal Lobes. — There are no localizing symptoms, unless the tumor 
be sufficiently deep to involve the visual tract, — i.e., the conducting 
fibres coming from the cuneus, — when it may produce hemianopsia, or 
be situated in the left angular or supra- marginal gyrus, when it may 
cause word- blindness. 

Occipital Lobes. — The only localizing symptoms are disorders of vision, 
ranging from slight subjective phenomena to complete hemianopsia due 
to involvement, less or more complete, of the cuneus or its conducting 
fibres. 

Central Ganglia. —Tumors of the optic thalamus and the striate bodies 
may exist without localizing symptoms, or may produce disturbances 
varying from the slightest loss of sensation or of motion to complete 
hemianaesthesia and hemiplegia, according as they encroach little or 
much upon the internal capsule. 

Temporal Lobe. — The only localizing symptoms are disturbances of 
hearing, especially word- deafness, which has been noted when the first 
and second gyri were affected. 

Basal Ganglia. — Tumors of the corpora quadrigemina produce ocular 
symptoms, and especially a very early developed optic neuritis ; not 
rarely hydrocephalus results from the pressure. If the crus be involved 
there may be hemiplegia with or without disturbances of sensation on 
the same side, and with or without oculo motor paralysis on the opposite 
side. 

Pons. — Tumors of the pons produce almost every conceivable form of 
spasm and of paralysis by involving the cranial nerves and the motor 
tracts going to the limbs, and also by similar involvement of the sensory 
tracts. The auditory nerve is not rarely paralyzed, with resultant deaf- 
ness. Facial paralysis, with opposing conjugate deviation of the eyes, 
appears to be diagnostic. 

Medulla. — Tumors involving the medulla may produce partial hemi- 
plegia with hemianesthesia on the opposite side, or partial paraplegia, 
or various disorders of swallowing, of respiration, of the heart's action, 
and of other functions of the nerves situated in this region. Ataxia is 
said to be a frequent symptom. 

Cerebellum. — Tumors of the lateral lobe of the cerebellum, unless by 
pressure they affect the central lobe, produce no localizing symptoms, 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 527 

but may be suspected when, without localizing symptoms, the general 
manifestations of brain-tumors are present, and are accompanied by ex- 
cessive vomiting and by a very early and intense development of choked 
disk. Tumors involving the central lobe of the cerebellum usually pro- 
duce intense headache, excessive nausea aad vomiting, and a persistent, 
distressing giddiness, which may be so severe as to confine the patient to 
a horizontal position or may chiefly consist of cerebellar titubation. (See 
page 488.) In some cases there is a distinct tendency to fall uniformly 
to one side, perhaps more frequently backward, or occasionally forward. 

The knee-jerk is probably never affected by a cerebral tumor unless 
the latter be located in the cerebellum or its neighborhood. Under these 
circumstances the knee-jerk may be wanting, normal, or exaggerated ; 
and it has happened under observation that the normal knee-jerk has 
gradually disappeared, and then reappeared and increased in activity 
until much above the norm. These alterations of the knee-jerk occur- 
ring in the course of a few weeks or months are probably diagnostic of 
tumor in the cerebellum or its neighborhood. The explanation is that 
in the beginning the tumor irritates Setschenow's centres and produces 
excessive spinal inhibition with loss of knee-jerk, but that as the tumor 
grows and invades Setschenow's centres these lose their functional power 
until all inhibition of the spinal cells is ended, in which case there must 
be exaggeration of the reflexes. 

It is a general rule that in basal brain-tumor optic neuritis, paralysis 
or spasms of the eye-muscles, irregularities of the pupil, nystagmus, or 
other symptoms due to irritation or to pressure of the nerves of the base 
of the skull, are present. 

Diagnosis. — Of the non-localizing symptoms the most important is 
optic neuritis ; this may occur in acute encephalitis, in multiple neuritis, 
and in chronic metallic poisonings, especially lead poisoning ; but prob- 
ably in ninety-eight per cent, of the cases it is the result of meningitis, 
hydrocephalus, or brain-tumor. In individual cases it may be impos- 
sible to decide whether the lesion is a basal meningitis or a basal brain- 
tumor. In syphiloma the exudation is so wide-spread that often it would 
be as correct to say that there was a syphilitic meningitis as to say that 
there was a gumma. 

The diagnosis of meningitis can usually be arrived at by a history of 
the existence of its cause, by the rapidity of its course, and by the age of 
the patient. Hydrocephalus occurring in infants is at once distinguished 
by the size and appearance of the head. 

A small brain-tumor may exist without causing optic neuritis ; but 
unless it give rise to focal symptoms the diagnosis must usually be long 
reserved and finally reached chiefly by exclusion,— that is, by the de- 
termination that no other explanation can be found for the symptoms 
which persist indefinitely. When dementia paralytica develops with 
epileptic attacks, followed by transitory paralysis, an error is possible, 



528 



DISEASES OF THE NERVOUS SYSTEM. 



but should be prevented by the peculiar alterations of the intelligence 
and by the absence of severe headache. 

In the advanced stages of cerebral tumor, when optic atrophy has 
occurred, a likeness to multiple sclerosis is possible. In the latter dis- 
order, however, there is little or no headache, very rarely vomiting, and 
still more rarely slowing of the pulse, whilst there are present the spinal 
symptoms which are absent in cerebral tumor. 

Acute encephalitis with optic neuritis is to be recognized by its rapid 
development with pronounced fever. 

The diagnosis as to the exact seat of the brain-tumor is to be made by 
carefully applying the principles of cerebral localization. Localizing 
symptoms which develop late in the course of a case are frequently due 
to secondary changes at a distance from the original tumor. Especially 
are tumors which are placed in or about the Sylvian fissure prone by 
pressure upon blood-vessels to cause distant softening. The diagnosis of 
the nature of a cerebral tumor can be nothing but a guess, unless such 
tumor be secondary to tubercular, carcinomatous, or other growths in 
distant parts of the body. 

Treatment. — In no form of cerebral tumor, except syphiloma, is 
medical treatment permanently effective. Removal of the tumor is prob- 
ably practicable in about three per cent, of the cases. An attempt at it 
is justifiable only when the tumor is clearly located in the psycho-motor 
zone and has positively resisted antisyphilitic treatment. When the 
headache is so atrocious that the patient prefers death to life, after ex- 
haustion of all other methods for relief, trephining for relief of pressure 
is a defensible procedure. 

Cerebral surgery as practised by various surgeons has been very valu- 
able to neurology by affording early post-mortems in cases which other- 
wise might, after some months, have drifted away from medical watching. 

CEREBRAL SYPHILIS. 

Definition. — Gummous inflammation or neoplasm in the brain or 
its membranes. 

Etiology. — Cerebral syphilis may appear within three months after 
primary infection, but usually is delayed from one to thirty years. It is 
especially liable to develop when the secondary symptoms have not been 
severe, and often occurs when both primary and secondary symptoms 
have been so slight as to escape observation on the part of the victim. 
Inherited syphilis is less prone to attack the nervous system than is ac- 
quired syphilis, but cerebral gummata may develop during intra-uterine 
life and at any time subsequently ; indeed, nervous syphilis may appear 
after puberty as the first open outbreak of inherited disease. 

Morbid Anatomy. — The cerebral gumma probably always has its 
origin in the membranes, is usually surrounded by a reddish zone, and 
does not become so uniformly and completely caseous as does tubercle, 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 529 

from which it is further distinguished by its proneuess to cause cerebral 
softening. In gummous meningitis the exudation forms an extended, 
shapeless, gelatinous mass, which is in the majority of cases situated at 
the base of the brain. Microscopically, the cerebral gumma differs from 
other similar bodies chiefly in the presence of very large, spider-like cells 
containing an exaggerated nucleus and a granular protoplasm, which 
extends into the multiple, branching, rigid prolongations. 

Under treatment gummata may disappear completely or may leave 
behind them cicatrices, imperfect cysts, or even calcareous masses. A 
gumma may involve a blood-vessel, and, extending along its wall, give 
rise to a thrombus with secondary softening, or it may lead to rupture 
of the vessel and intra- cerebral hemorrhages. A gummous inflammation 
commencing in the pia mater may infiltrate a wide extent of the cortex. 

Syphilitic sclerosis of the cerebral vessels is not rare, and the arteries 
of the base are especially prone to suffer from a peculiar destructive spe- 
cific lesion which renders them whitish, opaque, and hard, and finally 
almost obliterates their lumen. 

Symptomatology. — Although brain syphilis probably always develops 
somewhat slowly, yet the symptoms may appear most abruptly and vio- 
lently, headache, vertigo, or other prodromes having passed by unnoticed. 
Syphilitic fulminating coma may or may not be accompanied by convul- 
sions, by delirium, or by hemiplegia, monoplegia, or local paralysis. In 
its general symptoms it may conform to any variety of apoplectic or 
epileptic attack. 

The symptoms of chronic brain syphilis are so protean, so varying, that 
it is almost impossible to reduce them to any order. Malaise, a little 
brain -failure, a succession of causeless headaches, — these may for a time 
be all the outcome. After a greater or less continuance of these pro- 
dromes, epileptic attacks usually develop, with a hemiplegia or a mono- 
plegia which is almost invariably incomplete and usually progressive ; 
diplopia from weakness of ocular muscles, decided squint, or pronounced 
oculo- motor palsy may be manifested before the epilepsy. There is almost 
always distinct failure of the general health, with progressive intellectual 
deterioration, as shown by loss of memory, failure of the power to fix the 
attention, mental bewilderment, morbid somnolence, perhaps aphasia, 
and towards the end of life not rarely dementia. If the case convalesce, 
the amelioration will be gradual. A fatal ending is usually by a gradual 
sinking into complete paralysis, or the patient is carried off by an acute 
inflammatory exacerbation or by a very violent epileptic fit. Death 
from brain softening around the tumor is not infrequent, but a fatal apo- 
plectic hemorrhage is rare. 

It is almost impossible satisfactorily to reduce to any order or types 
the various forms of cerebral syphilis. Besides those cases which resem- 
ble dementia paralytica, Heubner makes two types : (1) psychical dis- 
turbances, with epilepsy, incomplete paralysis (seldom of the cranial 

34 



530 



DISEASES OF THE NERVOUS SYSTEM. 



nerves), and a final comatose condition, usually of short duration ; and 
(2) genuine apoplectic attacks with, succeeding hemiplegia, in connection 
with peculiar somnolent conditions occurring in often- repeated episodes ; 
frequently phenomena of unilateral irritation, and generally at the same 
time paralyses of the cerebral nerves. 

The only conformity of brain syphilis, as we have seen it, with these 
types is in the fact that when epilepsy is pronounced the basal cranial 
nerves are not usually paralyzed ; and it seems necessary to add two 
other types of disease, — namely : 

(3) Psychical disturbance without complete epileptic convulsions, as- 
sociated with palsy of the basal nerves and often with partial hemiplegia. 

(4) Paraplegia associated with ocular or other symptoms indicative 
of lesions at the base of the brain. 

In nature, however, there are no distinct varieties of cerebral syphilis, 
all forms grading one into the other, and it is most satisfactory to study 
the important symptoms separately. 

Headache is the most constant, and usually the earliest, of the symp- 
toms of meningeal syphilis, but it may be entirely wanting. It may last 
for several years without the development of other distinct symptoms, 
and sometimes disappears when these appear. It has no fixed character, 
but is usually paroxysmal, and may occur solely in the form of very dis- 
tinct and very violent paroxysms, accompanied by partial unconscious- 
ness or other marked congestive symptoms. Distinct soreness of the 
head indicates disease of the skull or its periosteum. 

Insomnia is a frequent prodrome of cerebral syphilis, but a pecu- 
liar somnolence is much more characteristic. The foudroyant coma has 
already been described : in the second variety of syphilitic stupor the 
symptoms develop gradually. The patient sits all day long or lies in bed 
in a state of semi- stupor, indifferent to everything, but capable of being 
aroused, answering questions slowly, imperfectly, and without complaint, 
but in an instant dropping off again into his quietude. In other cases the 
sufferer may still be able to work, but often falls asleep while at his tasks, 
and especially towards evening has an irresistible desire to slumber. 
This state of partial sleep may precede that of the more continuous stupor 
or may pass off when an attack of hemiplegia seems to divert the symp- 
toms. The mental phenomena in the more severe cases of somnolency 
are peculiar. The patient can be aroused, — indeed, in many instances 
he exists in a state of torpor rather than of sleep ; when stirred up he 
thinks with extreme slowness, and may appear to have a form of aphasia, 
yet at intervals he may be endowed with a peculiar automatic activity, 
especially at night. Getting out of bed ; wandering aimlessly and seem- 
ingly without knowledge of where he is, and unable to find his own 
bed ; passing his excretions in a corner of the room or in some other 
similar place, not because he is unable to control his bladder and bowels, 
but because he believes that he is in a proper place for such acts, — he 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 531 

seems a restless nocturnal automaton rather than a man. Apathy and 
indifference are the characteristics of the somnolent state, yet the patient 
will sometimes show excessive irritability when aroused, and will at other 
times complain bitterly of pain in his head, or will groan as though 
suffering severely in the midst of his stupor, — at a time, too, when he 
is not able to recognize the seat of the pain. We have seen a man with a 
vacant, apathetic face, almost complete aphasia, and persistent heaviness 
and stupor, arouse himself when the stir in the ward told him that the 
attending physician was present, and come forward in a dazed, highly 
pathetic manner, by signs and broken utterances begging for something 
to relieve his head. Heubner speaks of cases in which the irritability 
was such that the patient fought vigorously when aroused. 

After some days of excessive somnolence and progressive deepening 
of the stupor, or sometimes more rapidly, the victim of cerebral syphilis 
may pass into a condition of profound coma, out of which he cannot be 
aroused, and during which his fseces and urine are either not passed at 
all or are voided involuntarily. This condition of coma may end in 
death, but even when the symptoms seem most serious the patient may 
gradually recover, slowly emerging from coma into stupor, and from 
stupor into wakefulness and normal life. 

Motor paralysis sometimes develops gradually, but it may appear 
suddenly, with or without the occurrence of an apoplectic or epileptic 
fit. A paralysis which on the first return to consciousness is complete 
is usually due to clot or thrombus. 

The characteristic syphilitic palsy is progressive and incomplete. 
Any portion of the body may be involved, but the syphilitic exudation 
especially haunts the base of the brain, and a rapidly but not abruptly 
appearing strabismus, ptosis, dilated pupil, or any other paralytic eye- 
symptom not readily accounted for in the adult is, in the majority of 
cases, syphilitic. The specific palsy is often temporary, transient, and 
shifting. Sensory palsies are less frequent than motor palsies, but may 
occur in any form. Special- sense palsies are sometimes present, whilst 
specific aphasia is common. It may be incomplete, transitory, and par- 
oxysmal, but is more apt to be complete and to have permanency than 
are motor paralyses. Owing to the tendency of syphilis to produce mul- 
tiple lesions, a lack of apparent agreement between the palsy and the 
aphasia is almost characteristic. Thus, Tarnowsky found that out of 
thirty -two cases of syphilitic aphasia with hemiplegia in fourteen the 
paralysis was on the left side. Polyuria and true saccharine diabetes 
occur in cerebral syphilis, probably as the result of vaso motor disturb- 
ances. 

Epileptiform convulsions are most characteristic : an intense and pro- 
tracted headache, followed by an epileptic fit, in an adult should excite 
the greatest suspicion. Our experience is in accord with that of Fournier, 
that epileptiform convulsions not due to alcoholism or uraemia, and not 



532 



DISEASES OF THE NERVOUS SYSTEM. 



appearing until after thirty years of age, are in nine cases out of ten 
specific. The aura is rarely present ; the symptoms may be unilateral 
or even nionoplegic, but any variety of epileptiform convulsions may be 
simulated. Furious attacks of local spasms also occur without loss of 
consciousness. Then, again, the movements may be continuous and dis- 
tinctly choreic. 

Apathy, somnolence, loss of memory, and general mental failure are 
the most frequent and characteristic mental symptoms of meningeal 
syphilis ; but almost any form of insanity — mania, melancholia, erotic 
mania, delirium of grandeur, etc.— may be of specific origin. Usually, 
sooner or later, distinct symptoms of organic lesion appear. Especially 
common is a loss of mental and physical power similar to that which 
occurs in dementia paralytica. 

Diagnosis. — In the diagnosis of cerebral syphilis too much weight 
should not be attached to the history of the case, as non-syphilitic, 
organic brain disease may occur in persons who have had syphilis, and 
cerebral gummata may develop in persons who are unconscious of ever 
having been infected. 

The prodromes of foudroyant cerebral syphilis are worthy of the most 
careful study on account of their diagnostic value and of their habitu- 
ally being overlooked. Persistent headache, slight failure of memory, 
unwonted slowness of speech, general lassitude and disinclination to 
mental exertion, sleeplessness or excessive somnolence, attacks of mo- 
mentary giddiness, vertiginous feelings when straining at stool, yelling 
or in any way disturbing the cerebral circulation, alteration of disposi- 
tion, — any of these (and a fortiori several of them) occurring in a syphilitic 
subject should be the immediate signal for alarm. Of these prodromic 
symptoms the most important and characteristic are headache and som- 
nolence. Slight and shifting localized weaknesses sometimes precede an 
acute attack, but are more characteristic of the disease at a later stage. 
A momentary weakness of one arm ; a slight drawing of the face, dis- 
appearing in a few hours ; a temporary dragging of the toes ; a partial 
aphasia which appears and reappears ; a squint which to-morrow leaves 
no trace, — all or any of these may be due to a non-syphilitic brain-tumor, 
to miliary cerebral aneurisms, or to some other non-specific affection ; but 
in the majority of cases, when these phenomena occur repeatedly in a 
patient who is not suffering from hysteria they are the result of syphilis. 

In a doubtful case of sudden coma other ordinary causes must be elimi- 
nated : a pronounced rise of temperature or a pronounced conjugate de- 
viation of the head and eyes tells strongly against, whilst decided ocular 
palsy or a partial paralysis of any character argues in favor of, a specific 
origin. 

Headache occurring with palsy or with a history of attack of par- 
tial monoplegia or hemiplegia, vertigo, petit mal, epileptoid convulsions, 
disturbances of consciousness, attacks of unilateral or localized spasms, 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 533 

ocular palsies, epileptic forms of attacks occurring after thirty years 
of age, morbid somnolence, — any of these, even when existing alone, 
should put the practitioner upon his guard. Any apparent causeless- 
ness, severity, and persistency of headache should arouse suspicion, to 
be much increased by a tendency to nocturnal exacerbations or by 
the occurrence of mental disturbance or of giddiness at the crises of 
the paroxysms. ~Not rarely there are very early in these cases curious, 
almost indefinable, disturbances of cerebral functions which may be easily 
overlooked, such as temporary and partial failure of memory, word- 
stumbling, fleeting feelings of numbness or weakness, and alterations of 
disposition. In the absence of hysteria, any indefinite and apparently 
disconnected series of nerve-accidents is of very urgent import. To use 
the words of Hughlings- Jackson, U A random association or a random 
succession of nervous symptoms is very strong warrant for a diagnosis of 
a syphilitic disease of the nervous system." Cerebral syphilis occurring 
in an hysterical subject may be readily overlooked until fatal mischief is 
done. 

The age of the patient must also be taken into consideration. Apo- 
plexy occurs most frequently in persons over fifty years of age, while 
congestive syphilitic attacks are most common before that age. The 
course of a case for the first six or ten hours after the commencement of 
the acute paroxysm is sufficiently different in the two affections to be 
worthy of the closest study. A hemorrhagic or embolic apoplexy which 
is sufficiently severe to keep up pronounced disturbance of consciousness 
for some hours is almost invariably accompanied by a complete hemi- 
plegia, or more rarely by some other form of complete palsy ; whilst in 
the syphilitic attack the paralysis is often absent, and probably never 
complete. Unless the clot has been a very large one, the return to con- 
sciousness after hemorrhagic apoplexy is usually much more rapid than 
it ordinarily is in syphilitic cases. Headache after an apoplexy is rare, 
whilst it is very frequent after a severe syphilitic congestive attack. 

The peculiarities in the symptoms of cerebral syphilis are chiefly due 
to the fact that the lesions are apt to be multiple or wide-spread, to be 
rapidly developed at an age when other organic diseases are rare, and to 
be situated in the cerebral cortex or at the base of the brain. Hence 
multiple local or partial palsies are frequent, whilst the symptoms of the 
basal chronic meningitis in the non-tubercular adult are in the majority 
of cases the outcome of syphilis. Homonymous hemianopsia is very 
rare, because the occipital lobes are seldom invaded. Optic neuritis 
may occur in specific as in other brain diseases : it usually develops with 
moderate rapidity. 

The diagnosis of cerebral syphilis during life is always a matter of 
inference. When, however, the symptoms disappear under antisyphilitic 
treatment, for practical purposes the diagnosis may be considered as 
fixed. The therapeutic test is therefore a matter of the gravest impor- 



534 



DISEASES OF THE NERVOUS SYSTEM. 



tance. The old belief of syphilograpliers that tolerance of the iodides 
warrants the diagnosis of syphilis has been in recent times strongly com- 
bated, but we still think that, whilst it is not a positive sign, the tolerance 
strongly increases the probability of the existence of specific disease. 

Prognosis. — Although death may occur during a syphilitic convul- 
sion, yet the prognosis of an acute attack of cerebral congestion or in- 
flammation due to syphilis is on the whole favorable, although it should 
be somewhat guarded. In chronic brain syphilis the prognosis is favor- 
able for more or less complete recovery unless the symptoms indicate an 
absolute destruction of brain- tissue. "Whenever amendment of the symp- 
toms occurs under antispecific medication, more or less complete recov- 
ery becomes probable. As, however, unexpected accidents occasionally 
happen, it is best not to make the prognosis too absolute. 

Treatment. — The treatment of cerebral syphilis is best studied under 
two heads : first, the treatment of the accidents which occur in the course 
of the disease j second, the general treatment of the disease itself. 

In the accidents of cerebral syphilis the treatment should be that 
which is adapted to the relief of the same symptoms when dependent 
upon other than specific causes. Thus, in foudroyant coma, if there be 
pronounced arterial excitement, or if the patient's strength be good, 
venesection should be resorted to at once. We have seen life saved by the 
abstraction of nearly a quart of blood, whilst in other cases that of a 
few ounces has sufficed. Care must be exercised not to mistake a simple 
epileptiform convulsion for a pronounced congestion of the brain, but if 
there be epileptic status with repeated convulsions, or if there be violent 
delirious excitement, venesection may be resorted to if the patient's 
general condition permit. In severe cases the bleeding should be as 
rapid as possible from a large orifice, and be continued until a distinct 
impression is made upon the pulse. When the heart's action continues 
violent after venesection, the hypodermic injection of tincture of aconite 
root (two to four drops) may be given every half-hour until physiologi- 
cal effects are manifest. In feeble cases cupping to the back of the neck, 
stimulating injections, sinapisms to the extremities, cold to the head, 
croton oil as a derivative, and other classical remedial measures for brain 
congestion may be used. 

In chronic cerebral syphilis remedial measures looking to the relief of 
symptoms may occasionally be employed with temporary advantage, but 
are of comparatively little importance. 

The first therapeutic question to be decided is usually as to the choice 
between mercurials and the iodides. Cerebral gummata may develop in 
persons showing marked evidences of cachexia, but in the great majority 
of cases cerebral syphilis appears at a time when there is no general 
breaking down of the tissues or of the general system. The choice be- 
tween the remedies should rest upon the existing symptoms, and not 
upon the time which has elapsed between the primary infection and the 



ORGANIC DISEASES OF THE BRAIN AND ITS MEMBRANES. 535 

outbreak. When cachexia contra-indicates the free use of mercurials, or 
even of iodides, tincture of iron and corrosive sublimate may be given 
together. (Formula 10.) 

The slowness of action of the iodides may be serious. Death from an 
epileptic fit may be the penalty of delay. When there is no cachexia 
and no history of recent niercurialization, mercury should be given at 
once to slight salivation, and a mercurial impression, just below the line 
of slight tenderness of the gums, should be maintained for some days or 
weeks, pro re nata. 

The method of administering mercury should be suited to the exigen- 
cies of the individual case. If mercurials by the mouth are well borne, 
they should be so administered. If the symptoms are extremely urgent, 
the mercury may be given both by the mouth and by inunctions. When 
there is a tendency to diarrhoea, the mercurial inunction should be used 
alone. The oleate is not preferable to the old blue ointment : from a 
half- drachm to three drachms of either may be used at once. An excel- 
lent plan is to give a hot bath late in the afternoon, or better in the 
evening, and use the inunction on going to bed, ordering the patient to 
rub the ointment on Sunday night into the left axilla, on Monday night 
into the left flank, on Tuesday night into the inside of the left thigh, on 
Wednesday night into the right axilla, on Thursday night into the right 
flank, on Friday night into the right thigh, and on Saturday night into 
the region of the umbilicus ; after this recommencing with the left axilla. 

If the patient is willing to endure the local pain, the hypodermic 
injection of corrosive sublimate is sometimes extraordinarily efficacious. 
From one-twelfth to one-sixth of a grain dissolved in a drachm of dis- 
tilled water should be injected deeply into the muscles of the back daily 
or every other day, according to circumstances. 

After a prolonged mercurial course potassium iodide should always 
be given, in order to secure elimination of the mercury as well as to 
relieve the syphilis. The dose of the iodide must be suited to the indi- 
vidual case. The beginning daily dose should be thirty grains, rapidly 
increased to four drachms unless iodism results. There are cases of cere- 
bral syphilis in which not more than five or ten grains a day of the 
iodide can be tolerated, and in which such small dose accomplishes as 
much good as does the large dose in the ordinary case. It is often best 
to give the iodide in milk, or compound syrup of sarsaparilla may be 
used as the vehicle. The number of daily doses may be from four to six. 
The older preparations of the u woods," so called, seem sometimes to 
have special value : thus, Zitmann's decoction occasionally is successful 
in very old cases after the failure of the other mercurials. A fair imi- 
tation of this older prescription may be made by using as a vehicle for 
the iodide a mixture of equal parts of compound fluid extract and com- 
pound syrup of sarsaparilla. (Formula 11.) 



536 



DISEASES OF THE NERVOUS SYSTEM. 



CHAPTEE IY. 

DISEASES OF THE MEDULLA OBLONGATA. 

For a comprehension of the diseases of the mednlla oblongata it is 
essential that it be fully recognized that the medulla belongs not to the 
brain but to the spinal cord, both in its anatomy and in its physiology. 
The spinal cord entering the skull bends forward, so that the posterior 
portion of the cord becomes the upper surface of the medulla. The first 
change in structure is an opening of the posterior commissure of the 
spinal cord into the central canal : by this splitting process is formed the 
floor of the fourth ventricle. Then the lateral columns decussate ob- 
liquely, each crossing over to the opposite side of the medulla. During 
its passage across the medulla each column cuts the gray matter into 
three parts : out of each anterior horn of the gray matter of the spinal 
cord are formed two isolated parts, one representing the central portion 
of the gray matter and situated in the floor of the fourth ventricle, the 



Fig. 12. 




ABC D 

Diagram showing modification of spinal cord into medulla.— A, spinal cord ; D, medulla. 1, base 
of anterior horn ; 2, apex of anterior horn ; 3, base of posterior horn ; 4, apex of posterior horn. (After 
Grasset.) 



other representing the distal parts of the anterior horn of the spinal 
gray matter and situated deeply in the anterior portion of the medulla. 
The posterior horns of the spinal cord also undergo bisection, each being 
separated like the anterior into two tracts, of which one, representing 
the central part of the cord, is in the floor of the fourth ventricle, and 
the other, representing the distal gray matter of the cord, is deep in the 
medulla. 

It is plain that the nuclear mass situated in the floor of the fourth 
ventricle represents the whole of the central portion of the gray matter 
of the spinal cord, from which have been cut off the ends of both the 
anterior and the posterior horns. In the central ganglionic mass — i.e., 



DISEASES OF THE MEDULLA OBLONGATA. 



537 



the floor of the fourth ventricle — are the pneumogastric and respira- 
tory centres and the nuclei of the abducent, facial, auditory, and glosso- 
pharyngeal nerves ; from it also go sensory fibres to the trigeminal and 
other mixed nerves. 

Out of the deep-seated gray matter in the medulla which represents 
the extreme posterior horns come sensory fibres for the glosso-pharyngeal 
and pneumogastric nerves ; whilst in the deeply situated gray substance 
which represents the extreme anterior horns of the spinal cord are nuclei 
of the spinal, pneumogastric, and hypoglossal nerves. 

In the gray matter of the spinal cord are situated the trophic cells 
of tributary muscles, and the gray masses in the medulla which repre- 
sent isolated portions of the spinal gray matter preserve the functions 
of the latter, and are the trophic centres of the various nerves which 
originate in the medulla and are supplied to the muscles of the head 
and neck. 

When the anatomy and physiology of the medulla oblongata are com- 
prehended it must be apparent that its diseases are those of the spinal 
cord, the only differences being in the distribution of the various motor 
and sensory disturbances induced. Owing, however, to the greater ac- 
tivity of its circulation, the medulla suffers more frequently from hem- 
orrhages into it than do the strictly spinal centres. It is, in its turn, 
much less frequently attacked than is the brain. The results of bulbar 
hemorrhages have been sufficiently treated under the general head of 
apoplexy. (See page 501. ) Foreign growths in the medulla oblongata 
produce localizing symptoms by disturbances of the nerves which come 
from the medulla, and also cause a more or less pronounced hemiplegia 
or general paralysis by pressing upon or otherwise interfering with the 
function of the descending pyramidal tract or tracts. 

Any lesion which irritates the pneumogastric centre will produce 
slowing of the heart, whilst a lesion which paralyzes the pneumogastric 
centres will register itself in rapidity of heart-action. Lesions of the 
respiratory centre produce most serious and often fatal disturbances of 
the respiration. 

In multiple cerebro spinal sclerosis the formation of the nodule in the 
medulla oblongata is followed by symptoms of irritation or paralysis 
corresponding to the seat of the nodule. For a detailed description of 
the symptoms which follow paralysis of the various nerves having origin 
in the medulla oblongata, see article on Local Paralyses. 

GLOSSO-LABIAL PARALYSIS. BULBAR PALSY. 

Definition. — A poliomyelitis affecting the motor centres in the 
medulla oblongata, with consequent paralysis and trophic changes in 
the tributary muscles. 

Glosso-labial paralysis is in no proper sense a distinct disease ; it is 
only a form of chronic poliomyelitis, and may or may not be associated 



538 



DISEASES OF THE NEEYOTTS SYSTEM. 



with similar lesions in other portions of the spinal system and the conse- 
quent symptoms of so-called progressive muscular atrophy in the affected 
parts. We retain the distinct heading simply out of deference to a custom 
which originated before the nature of the disease was understood. Its 
etiology and pathology are those of poliomyelitis. 

Symptomatology. — The chief symptoms of this disease are a pro- 
gressive loss of power in the tongue, lips, palate, and muscles of the 
throat, associated with wasting and fibrillary contractions in the af- 
fected muscles. The tongue is protruded more slowly and imperfectly 
than is normal, and becomes more and more tremulous. Owing to loss 
of control over it, the pronunciation of the lingual vowels and of the 
dental consonants is imperfect. The weakness of the lips shows itself 
by the failure in articulation of the labial consonants, by the inability 
to whistle, by tremulousness, and, finally, by the loss of the power of the 
mouth to retain the saliva, which dribbles constantly. As the disease 
is almost always symmetrical, the mouth is not drawn to one side, but 
the wasting of the parts about it may be sufficient to make the orifice 
appear much larger than normal and to confuse the naso-labial folds. 
Sometimes the lips during laughter separate, but are incapable of spon- 
taneously returning to their natural position, so that the patient is forced 
to replace them with the fingers. If the palate is markedly affected, 
the voice becomes nasal. 

Deglutition may be affected early or late in the disorder, and, as the 
loss of power of swallowing is paralytic, liquids are swallowed with much 
difficulty and are apt to be returned through the nose. In some instances 
the larynx is attacked and the voice becomes almost inaudible, without, 
however, being completely lost. In those cases in which the nuclei of 
the respiratory nerves are implicated the respiratory muscles undergo 
wasting and the respiration is much affected. Any attempt at violent 
movement, or, later in the disease, even ordinary walking, may cause a 
severe attack of dyspnoea. At last these cyanotic crises come on spon- 
taneously in furious paroxysms, which may occur either by day or by 
night. A peculiar symptom which especially characterizes this dyspnoea 
is a sensation of excessive fulness of the chest, which is probably pro- 
duced by the feebleness of the muscles preventing them from thoroughly 
emptying the lungs. In some cases the nuclei of the cardiac nerves 
appear to be attacked, and cardiac crises become violent and alarming. 
These are especially apt to be present in those persons in whom the 
respiration is affected, but may occur without the respiratory muscles 
suffering. The pulse in the cardiac crises is very feeble, irregular, inter- 
mittent, and at last may be imperceptible. The face is exceedingly pale 
and anxious, and there is habitually an intense terror, with a sense of 
impending death. The ocular muscles may be affected in bulbar palsy, 
although they usually escape. 

Peogxosis. — Death always results, — in rare cases in a few months, 



DISEASES OF THE MEDULLA OBLONGATA. 



539 



more commonly in from one to three years ; usually from paralytic inter- 
ference with swallowing or breathing. 

Diagnosis. — Glosso-labial paralysis may be confounded with the 
very rare instances in which multiple lesions in the cerebrum influence 
especially the muscles of the mouth, tongue, and throat. There should, 
however, be no difficulty in recognizing the true nature of the pseudo- 
bulbar paralysis, because the paralyzed muscles do not undergo atrophy, 
and because almost of necessity there must be associated with the bulbar 
symptoms hemiplegic or other forms of motor paralysis or spasm, and 
also disturbances of intellection or of the special senses. 

A number of very curious cases have been reported by Goldflams, 
Erb, and others, in which the symptoms closely resembled those of 
bulbar paralysis, but in which careful studies of the medulla made after 
death failed to detect any lesions. According to Oppenheim, these cases 
agree in having, besides the throat and mouth symptoms, ptosis, and 
weakness of the muscles of the rump and of the extremities ; and, fur- 
ther, in the fact that there is no wasting of the affected muscles. The 
nature of the lesion is entirely obscure ; it may be that the cases repre- 
sent a hitherto undescribed disease, but it is more probable that they 
are instances of neuritic atrophy (see page 615) especially affecting the 
medulla oblongata. In a rapid case of apparently bulbar paralysis, which 
was atypical in the presence of bilateral complete facial paralysis and of 
trigeminal neuralgia, and which ended after four weeks in death from 
dyspnoea and collapse, Eisenlohr found that the lesion was a multiple 
neuritis. 

Treatment. — There is no known specific effective treatment of 
glosso-labial paralysis. As the power of swallowing becomes impaired, 
great care to prevent choking should be exercised. Crises must be treated 
symptomatically. 



540 



DISEASES OF THE NERVOUS SYSTEM. 



CHAPTEE V. 

ORGANIC DISEASES OF THE SPINAL CORD AND ITS MEMBRANES. 
SPINAL LOCALIZATION. 

Localization of spinal disease is twofold : it relates disease, in the 
first place, to the anatomico-physiological tracts of the spinal cord, and, 
in the second place, to the vertical position of the lesion in the cord. 
The white matter of the spinal cord is divided into certain so-called 
longitudinal tracts or columns, which are set forth in the accompanying 
diagram. 

Fig. 13. 




Diagrammatic section of the spinal cord. 

The posterior median column, or the column of Goll, lies immediately 
in contact with the posterior fissure of the cord. It is composed chiefly 
of fibres which enter through the posterior nerve-roots and pass upward. 
The increase in the size of the column of Goll from below upward does 
not seem to be sufficient for the accommodation of all the fibres that 
enter the column, supposing that these fibres continuously travel upward 
to the brain ; and, further, the function of the column of Goll still remains 
in doubt : it is, indeed, probable that some or possibly all of the fibres 
escape from the column before reaching its summit, but how or where such 
escape is made remains as yet uncertain. 

Next to the column of Goll lies the postero-external column, the 
column of Burdach, or the posterior root-zone, chiefly composed of ver- 
tical fibres, whose function is at present unknown. 

The direct cerebellar tract seems to be chiefly composed of fibres 
which enter it through the lateral column from the gray substance and 
pass upward. It seems to have the function of conducting impulses 
upward, and, according to Mechsig, it probably carries impressions from 
the muscles of the trunk. 

Both the lateral pyramidal tract, " crossed cerebral tract," and the 
anterior pyramidal tract, " direct cerebral tract," or column of Turck, 



ORGANIC DISEASES OF THE SPINAL COED AND ITS MEMBRANES. 541 



Fig. 14. 



ic 



are composed of fibres whose course is downward from the pyramids of 
the medulla. At the decussation of the pyramids about three-fourths of 
the fibres cross to form the lateral tract, whilst the remaining fourth of 
the fibres enter the cord without decussation and constitute the anterior 
tract. The fibres of both pyramidal tracts finally pass through the gray 
matter of the spinal cord into the anterior horns, and, although they 
have not been traced, almost certainly end in the processes of the motor 
cells. Their function is to conduct from above downward, and they prob- 
ably constitute the pathway by which impulses from the motor regions of 
the cerebral cortex reach the motor ganglionic cells of 
the spinal cord, whose answering discharges provoke 
the final muscular contraction. 

The remaining portion of the white matter of the 
spinal cord is composed, first, of the so-called antero- 
lateral ascending tract (A.L., A.T.), which forms the 
periphery of the anterior portion of the cord ; second, 
of the mass of white fibres marked in the diagram as 
the anterior ground-fibres. The functions of these 
portions of the spinal cord have not been made out. 
Flechsig also anatomically separates the little patch 
of white matter between the lateral pyramidal tract 
and the gray matter, known as the lateral limiting 
layer. The separation of the antero-lateral tract 
from the so-called anterior ground -fibres does not 
seem to be at present warranted, either on anatomi- 
cal or on physiological grounds. Indeed, it is doubt- 
ful whether there is sufficient continuity, either of 
structure or of function, for any of the parts of the 
spinal cord spoken of in this paragraph to be con- 
sidered as distinct columns or tracts ; also whether 
any degeneration ever follows the course of these 
regions. 

The gray matter of the spinal cord, besides numer- 
ous conducting fibres, contains ganglionic cells whose 
processes are prolonged into nerve- fibres composed 
solely of the axis- cylinders. The ganglionic cells are 
arranged in groups which vary in different portions 
of the cord, and probably in the same portion of the 
cord in different individuals. The most readily recog- 
nized of the groups are the small inner or medial 
group, situated in the inner anterior angle of the horns ; the large anterior 
group, placed near the anterior edge of the horns, in the middle or a little 
to the outer side of the middle of the margin 5 the anterior lateral group, 
situated in the outer extremity of the front of the horns (the last two 
groups frequently consolidate) ; and the external or posterolateral group, 



Anatomy of the spinal 
cord (after Gowers).— C, cer- 
vical ; D, dorsal ; L, lum- 
bar ; S, sacral ; Co, coccyx. 



542 



DISEASES OF THE NERVOUS SYSTEM. 



which is usually the largest and is extended in the posterior outer angle 
of the cord. 

The most condensed statement of the facts necessary for the practi- 
tioner to know for the purpose of locating vertical lesions of the spinal 
cord is in the table of Starr. By means of this table and Fig. 14 the 
vertical position of almost any spinal lesion can be determined. In 
studying the diagram and table it must be remembered that the cervical 
cord is divided into eight segments, and that "II. and III. C." in the 
first column of the table refers to second and third cervical segments ; that 
the dorsal cord is divided into twelve segments, "I. D.," and so on ; that 
the lumbar cord is divided into five segments, and the sacral also into 
five segments ; thus, "III. to Y. S." means third to fifth sacral segments. 



Segment. 


Muscles. 


Reflex. 


Sensation. 


n. and m. C. 


Sterno-mastoid. 
Trapezius. 

Scaleni and neck. 
Diaphragm. 


Hypochondrium (?). 

Sudden inspiration produced 
by sudden pressure beneath 
lower border of ribs. 


Back of head to vertex. 
Neck. 


IV. c. 


TYi €\ Wh ra crm 
XJlcbpilL cLq J 11. 

Deltoid. 
Biceps. 

Coraco-brachialis. 
Supinator longus. 
Rhomboid. 

Supra- and infra-spinatus. 


"PiTnil "EYvnrtVi tn cipvpntli pAr. 

vical. 

Dilatation of the pupil pro- 
duced by irritation of neck. 


Upper shoulder. 
Outer arm. 


V. c. 


Deltoid. 
Biceps. 

Coraco-brachialis. 
Brachialis anticus. 

Supinator longus. 
Supinator brevis. 
Rhomboid. 
Teres minor. 

Pectoralis (clavicular part). 
Serratus magnus. 


Scapular. 

Fifth cervical to first dorsal. 

Irritation of skin over the 
scapula produces contrac- 
tion of the scapular muscles. 

Supinator longus. 
Tapping its tendon in wrist 
produces flexion of forearm. 


Back of shoulder and arm. 
Outer side of arm and fore- 
arm, front and back. 


VI. c. 


Biceps. 

Brachialis anticus. 
Pectoralis (clavicular part). 

Serratus magnus. 
Triceps. 

Extensors of wrist and fingers. 
Pronators. 


Triceps. 

Fifth to sixth cervical. 
Tapping elbow tendon pro- 
duces extension of forearm. 

Posterior wrist. 
Sixth to eighth cervical. 
Tapping tendons causes ex- 
tension of hand. 


Outer side of forearm, front 
and back. 

Outer half of hand. 


vn. c. 


Triceps (long head). 

Extensors of wrist and fingers. 
Pronators of wrist. 

Flexors of wrist. 
Subscapular. 

Pectoralis (costal part). 
Latissimus dorsi. 

Teres major. 


Anterior wrist. 

Seventh to eighth cervical. 
Tapping anterior tendons 
causes flexion of wrist. 

Palmar ; seventh cervical to 
first dorsal. 

Stroking palm causes closure 
of fingers. 


Inner side and back of arm 
and forearm. 

Radial half of hand. 



DISEASES OF THE SPINAL CIRCULATION. 



543 



Muscles. 



Reflex. 



Sensation. 



Flexors of wrist and fingers. 

Intrinsic muscles of hand. 

Extensors of thumb. 
Intrinsic hand-muscles. 
Thenar and hypothenar emi- 
nences. 

Muscles of back and abdo- 
men. 



Erectores spinse. 



Ilio-psoas. 



Sartorius. 

Muscles of abdomen. 



Ilio-psoas. 
Sartorius. 

Flexors of knee (Remak). 

Quadriceps femoris. 

Quadriceps femoris. 

Inner rotators of thigh. 
Abductors of thigh. 

Abductors of thigh. 

Abductors of thigh. 
Flexors of knee (Ferrier). 

Tibialis anticus. 

Outward rotators of thigh. 

Flexors of knee (Ferrier). 
Flexors of ankle. 
Extensors of toes. 

Flexors of ankle. 
Long flexor of toes. 



Peronei. 

Intrinsic muscles of foot. 



Perineal muscles. 



Epigastric, fourth to seventh 
dorsal. 



Tickling mammary region 
causes retraction of the epi- 
gastrium. 

Abdominal seventh to elev- 
enth dorsal. 

Stroking side of abdomen 
causes retraction of belly. 

Cremasteric, first to third lum 
bar. 



Stroking inner thigh causes 
retraction of scrotum. 

Patellar tendon. 

Striking tendon causes exten- 
sion of leg. 



Gluteal. 

Fourth to fifth lumbar. 
Stroking buttock causes dim- 
pling in fold of buttock. 



Plantar. 

Tickling sole of foot causes 
flexion of toes and retrac- 
tion of leg. 



Foot reflex. 
Achilles tendon. 
Over-extension of foot causes 
rapid flexion ; ankle-clonus. 
Bladder and rectal centres. 



Forearm and hand, inner 
half. 



Forearm, inner half. 
Ulnar distribution to hand. 



Skin of chest and abdo- 
men in bands running 
around and downward, 
corresponding to spinal 
nerves. 

Upper gluteal region. 



Skin over groin and front 
of scrotum. 



Outer side of thigh. 



Front and inner side of 
thigh. 



Inner side of thigh and leg 
to ankle. 

Inner side of foot. 



Back of thigh, back of leg, 
and outer part of foot. 



Back of thigh. 

Leg and foot, outer side. 



Skin over sacrum. 

Anus. 

Perineum. 

Genitals. 



SPINAL HEMORRHAGE. 

Hemorrhage may take place into the spinal cord itself, constituting 
the so-called hcematomyelia or spinal apoplexy ; or it may occur into the 
membranes of the spinal cord, when it is known as hwmatorrhachis. 

Haematomyelia is almost always secondary to various diseases of the 
spinal cord ; theoretically, however, it may occur without preceding ob- 
vious organic disease of the spinal cord as the result of degeneration of 



544 



DISEASES OF THE NERVOUS SYSTEM. 



the coats of the blood-vessels. Hsematorrhachis may be secondary to 
diseases or traumatism of the membranes, but is not very rare as a con- 
sequence of syphilitic or other disease of the blood-vessels. 

In hsematomyelia, with or without loss of consciousness, there is a 
sudden motor and sensory paralysis of all the parts below the seat of the 
hemorrhage. Pain is very rarely severe, and is often practically wanting. 
The bladder and rectum are immediately implicated. Myelitis is usually 
rapidly developed, with loss of reflexes, muscular atrophy, decubitus, etc. 
The prognosis is absolutely grave, and no treatment is of distinct value. 
The greatest care should be taken to prevent the development of bed- 
sores. 

In hsematorrhachis the paralysis comes on rapidly, but not abruptly, 
requiring from a few minutes to some hours for its completion. It is 
accompanied with great pain in the back and tearing "tiger- claw" or 
burning pains in the extremity, which are due to the blood as it forces its 
way along the membranes, tearing or stretching the sensory nerve-roots. 
Muscular spasms may occur from irritation of the anterior roots. The 
anaesthesia is usually not as complete as in spinal hemorrhage, nor does it 
at its upper limits cease as abruptly. The bladder and rectum are para- 
lyzed, unless the hemorrhage is a very small one, when all the symptoms 
are imperfectly developed. 

In most cases the diagnosis between hsematomyelia and ha^matorrhachis 
is easy. If, however, a very large vessel bursts in the spinal membranes, 
the symptoms, except in the presence of severe pain, may closely simulate 
those of an intra-spinal hemorrhage. The prognosis of hsematorrhachis is 
very serious, most of the cases ending fatally. When the hemorrhage is 
very small, however, recovery with some impairment of function is pos- 
sible. There is no specific treatment. In a robust subject venesection 
would be justifiable. 

SPINAL EMBOLISM AND THROMBOSIS. 

Embolic and thrombotic arrest of circulation, except as secondary 
complications of previously existing diseases in the spinal cord, are among 
the rarest of clinical phenomena. If a vessel of any size were affected the 
symptoms would resemble those of intra-spinal hemorrhage ; and as a 
secondary result of such arrest of circulation there would be a softening 
of the spinal cord similar to the softening of the brain. Such pathological 
condition of the spinal cord has been recognized, and is usually spoken 
of as due to a myelitis. True softening is, however, always necrobiotic, 
and even if it be associated with a neoplasm or a localized inflammation 
of the spinal cord is not inflammatory, but is due to interference with 
the circulation by the neoplastic or inflammatory products. It is also 
probable that in some cases wide-spread degeneration of the vessel- walls 
may lead, without absolute arrest of circulation, to softening of the spinal 
cord. The symptoms which accompany softening are progressive paralysis 



DISEASES OF THE SPINAL CIRCULATION. 



545 



of the functions of the part affected, without fever, spasm, or other evi- 
dences of irritation. The prognosis is hopeless ; treatment without avail. 

SPINAL ANEMIA. 

Under the name of spinal anaemia is described by various authorities 
a hysteroidal condition (see page 409) which, so far as we have any definite 
information, has no connection or relation with anaemia of the spinal cord. 
We have little knowledge concerning true spinal anaemia, but it is certain 
that a violent hemorrhage, or a violent purgative, will occasionally pro- 
duce a partial paraplegia which is recovered from in due time ; and it is 
natural to explain such paraplegia by the theory of loss of power in the 
spinal centres from failure of proper blood-supply. In profound essential 
anaemia tingling and numbness, with some loss of muscular power in the 
legs and arms, are sometimes seen, and may be due to lack of blood in the 
cord. Degenerations of the cord certainly occur, however, in pernicious 
anaemia, and if during anaemia a complete paraplegia develops it is prob- 
ably always hysterical or organic. The loss of functional activity of the 
spinal cord from bloodlessness is to be treated by absolute rest, highly 
nutritious diet, iron, strychnine, bitter tonics, etc. 

HYPEREMIA OF THE SPINAL CORD. 

Concerning hyperaemia of the cord itself we have no definite know- 
ledge. It is possible that various neurasthenic symptoms are due to loss 
of power in the blood-vessels of the cord and consequent local congestion. 
Hemorrhage into the cord is said to have been produced by excessive 
coitus, and probably in sexual exhaustion local weakness of the blood- 
vessels in the lumbar cord from frequent excessive distention is an influ- 
ential factor. 

It is further probable that there is a form of ascending paralysis, so 
called (see Landry's paralysis), in which the lesion is an intense conges- 
tion of the enormous plexus of veins surrounding the spinal cord and 
of the vessels within the cord. Certainly we have seen cases in which, 
after excessive exertion with exposure, numbness, partial paraplegia, and 
lessening of reflex activity have rapidly developed, and increased and 
ascended until death from paralysis of respiration has occurred ; and at 
the autopsies we have found great engorgement of the vessels with serous 
exudation, or, in other words, a condition of the cord similar to so-called 
serous apoplexy in the brain. 

Whenever, after violent exertion, violent sexual excitement with 
repeated coitus, or the like, symptoms suggesting congestion of the 
spinal cord are present, if the patient be robust, general blood-letting 
and wet and dry cupping along the vertebral column may be practised. 
If numbness and weakness persist, absolute rest in bed on the side (not 
on the back) should be prescribed, and ergot freely given (a drachm 
a day of the extract). In the very beginning of such an attack large 

35 



546 



DISEASES OF THE NERVOUS SYSTEM. 



hypodermic injections of the extract of ergot might advantageously be 
given. 

ACUTE SPINAL MENINGITIS. 

Definition. — An acute inflammation of the spinal membranes, not 
syphilitic. 

Some authorities distinguish between acute spinal pachymeningitis, or 
inflammation of the dura mater, and acute leptomeningitis, or inflammation 
of the arachnoid or pia mater. Almost invariably, however, all the mem- 
branes are affected, though it is alleged that septic and traumatic menin- 
gitis may be confined to the dura mater. 

Etiology. — Acute spinal meningitis is anlrmed to' be sometimes pro- 
duced by severe exposure to heat or cold, but in the great majority of 
cases it is due to infection. It occurs most frequently in young males. 

Pathology. — In its pathological anatomy spinal meningitis is com- 
pletely parallel to cerebral meningitis. 

Symptomatology. — Acute spinal meningitis usually begins with a 
febrile disturbance, accompanied by severe pain along the whole back, 
soon spreading throughout the body and limbs. The spinous processes 
are not tender, but motion of the body or limbs usually increases the pain. 
Violent tonic spasms come on in a very few hours, spreading from the back 
muscles to the whole body, and result in opisthonotos or other forced 
positions of the trunk and rigid flexion of the limbs. The spasm and pain 
produced by attempts at motion give an appearance of paralysis, but until 
very late in the disorder there is little true loss of muscular power. The 
reflexes are grossly exaggerated ; retention of urine and constipation com- 
monly develop early j hyperesthesia is in most cases an early symptom, 
but may finally give place to anaesthesia, which is apt to occur in patches. 
Consciousness and intellection are not primarily affected, but there may 
be delirium and even coma before death. 

Diagnosis. — The only disease with which spinal meningitis can readily 
be confounded is rheumatism. The rapid development of the symptoms, 
the universality of the pain and spasm, the wide-spread hyperesthesia, 
the exaggeration of the reflexes, and the general severity of the attack 
characterize the spinal disease. 

Prognosis. — Death may occur in two days, but if the patient survive 
a week, recovery, with more or less permanent disablement from con- 
tractures and paralyses, is the ordinary result. The more severe the 
symptoms the more guarded should be the prognosis. A sudden great 
rise of temperature or a serious interference with respiration or with 
deglutition usually presages death. 

Treatment. — Blood-letting, general or local, the rapid induction of 
ptyalism by mercurial inunction, and the use of very active counter-irrita- 
tion over the back, find their justification in the seriousness of the local 
disease in cases of sthenic type with no apparent infection ; in infectious 
cases mild counter-irritation constitutes about the whole direct treatment. 



DISEASES OE THE SPINAL MEMBRANES. 



547 



Absolute quiet and rest should be enjoined. The food at first should be 
liquid, non-stimulating, and moderately nutritive, but afterwards should 
be both nutritive and stimulating. During convalescence absolute care 
must be enjoined to protect from any chilling of the surface or any fatigue 
of the nervous or the muscular system. 

CHRONIC SPINAL MENINGITIS. 

Definition. — A chronic inflammation of the spinal membranes. 

Chronic spinal meningitis may be localized or general. 

The most important local form is the cervical pachymeningitis of Char- 
cot, which usually, if not always, is of syphilitic origin. After death the 
cervical spinal membranes are found enormously thickened and accompa- 
nied by secondary changes in the cord and nerve-roots, due to pressure. 
Two stages of the disease are recognized : first, that of irritation ; second, 
that of paralysis ; but the separation of these two stages is artificial. Pain 
in the back of the neck, extending into the head and along the arms, asso- 
ciated with stiffness and muscular weakness of the parts and increased by 
movement, constitutes the chief symptom of the first stage. Vesicular or 
other trophic skin-lesions due to inflammation of the nerve-roots are often 
present. The second or paralytic period is characterized by loss of mus- 
cular power, with muscular atrophy especially affecting the domain of the 
ulnar and median nerves, and followed by contractures which extend the 
hand and the forearm and flex the fingers into a claw-like position. The 
disease may finally ascend upward and downward and give rise to wide- 
spread symptoms of chronic meningitis. The treatment of cervical pachy- 
meningitis should be actively antisyphilitic until success or failure is 
reached. Long- continued and severe counter-irritation (with the actual 
cautery) is also indicated. In the advanced disease no treatment is of 
avail. 

Generalized chronic spinal meningitis is almost always alcoholic, specific, 
or traumatic. Its most important symptoms are pain in the back and 
limbs, increased by active or passive movements ; hyperesthesia, perhaps 
associated with spots of angesthesia ; heightening of the reflexes, or in ad- 
vanced stages loss of the reflexes ; muscular contractures, followed by loss 
of power and wasting of the muscles. Mercurials and iodides should be 
administered, absolute rest should be enjoined, and the actual cautery 
or other counter-irritant should be freely and repeatedly used, unless 
failure to improve shows that the case is hopeless. Analgesics, hyp- 
notics, and similar remedies may be given pro re nata. 

SPINAL ABSCESS. 

Abscess of the spinal cord is probably always infectious: it may 
be suspected when severe spinal symptoms rapidly develop during a 
septicemia. It ends in a destructive myelitis, which is almost invariably 
fatal. 



548 



DISEASES OF THE NERVOUS SYSTEM. 



SPINAL TUMOR. 

Almost any form of neoplasm may be formed inside of the spinal 
column, producing symptoms which vary according to the size, position, 
and rapidity of growth of the tumor. The symptoms can best be studied 
as cord-symptoms and root-symptoms. 

The cord-symptoms are sharply limited, — loss of motion and sensation, 
with heightening of the reflexes, and without trophic changes. If the 
tumor be of very slight growth, one side of the spinal cord may be so 
pressed upon as to lose its functional power much earlier than the other 
part ; indeed, one function of one-half of the cord may be primarily 
affected. In this way a sensory or a motor monoplegia or a coexistent 
sensory and motor monoplegia may result from a tumor. 

The root-symptoms are most marked when the tumor is of such char- 
acter that it spreads into and involves the nerve-roots. They consist of 
pain, spasm, and motor and sensory paralysis, followed, it may be, by 
atrophy of the affected muscles, with reaction of degeneration. 

The pain of a spinal tumor may be slight or atrocious. It may consist 
of a heavy localized ache deep in the back, but usually is a burning, 
lancinating, tearing pain, following the course of the nerves and girdling 
the body in an agony, or more rarely affecting the arms or legs. Com- 
plete anaesthesia may finally be produced without abatement of the pain, 
constituting a form of anesthesia dolorosa which is almost characteristic 
of cancer. 

Diagnosis. — The recognition of a spinal tumor depends upon the 
slow simultaneous development of sensory and motor paralysis, without 
trophic changes or loss of reflexes, and the abrupt limitation of this paral- 
ysis by a narrow zone of partial palsy. In other words, the connection 
between the cord and the brain is severed, and an abrupt line of motor 
and sensory paralysis marks the seat of the separation of conduction. 
Trophic changes can occur only as the result of secondary lesions of the 
cord. A tumor is distinguished from the transverse myelitis of spinal 
caries by the slowness of its development and by the lack of tenderness 
upon direct or indirect pressure upon the vertebrae. Atrocious pain is 
characteristic of the cancerous tumor, but the caries which produces a 
transverse myelitis may also be attended with great pain, due to a sec- 
ondary inflammation of the sensory nerve-roots. 

Treatment. — There is no effective medicinal treatment for a non- 
specific spinal tumor. If the tumor have been accurately located, and 
be not cancerous or syphilitic, surgical interference will be justifiable. 

ACUTE ASCENDING PARALYSIS. LANDRY'S PARALYSIS. 

Definition. — An acute disease of uncertain pathology, characterized 
by the rapid and progressive development of motor paralysis, usually 
commencing in the lower extremities, and finally involving the whole 



DISEASES OF THE SPINAL COED. 



549 



muscular system ; without trophic alterations, or pronounced disturb- 
ances of sensation, but with enlargement of the spleen and lymphatic 
glands. 

Etiology. — Acute ascending paralysis has in various cases been 
attributed to exposure or recorded as a sequel of an infectious disease, 
but is still of very doubtful etiological relations, especially in view of 
the fact that the recorded cases probably represent several different 
diseases. 

Morbid Anatomy. — Focal myelitis and multiple neuritis have been 
recorded as the essential lesions of cases of ascending paralysis, but do 
not belong to the disease. Typical ascending paralysis may result in 
death without a lesion either of the nerve-centres or of the nerve-trunks 
that can be recognized by our present methods. The excessive venous 
congestion and increase in the cerebro spinal liquid found after death in 
some of these cases suggest that the disease is an acute congestion of the 
spinal cord with oedema ; but, on the other hand, in some of the cases 
there is no such congestion, so that it would seem either that there are 
two distinct diseases, one congestion of the cord, one something else 
having the same symptoms, or else that the congestion is a secondary 
result of the original disease, and not the cause of the symptoms. Under 
these circumstances two theories of the disease naturally confront us : the 
one that the lesion is an acute inflammatory hyperemia, which may dis- 
appear at death or may produce changes which we can recognize ; the 
other that the symptoms of Landry's paralysis are due to a toxsemia. 
The second of these theories seems at present the more probable. The 
enlargement of the spleen and of the lymphatic glands strongly indi- 
cates that the disease belongs to the infectious class and is due to the 
presence of micro-organisms. In corroboration of this, Baumgarten and 
Curschmann assert that they have found bacteria in the enlarged glands ; 
but Westphal, Kahler and Pick, and others have looked for them in 
these places without success. Centanni found in a typical case of Landry' s 
paralysis a peculiar bacillus, which existed in moderate numbers in the 
spinal cord, but in great numbers in the peripheral nerves, where it 
formed colonies which had resulted in structural alterations of the nerve- 
fibres, not of the nature of neuritis, but of a neuromycosis. This dis- 
covery of Centanni' s has been confirmed by Eisenlohr, who in two cases 
found a wide-spread, partially interstitial, partially parenchymatous alter- 
ation of the peripheral nerves extending to the extreme end-filaments 
of the nerves, caused by the presence of various forms of micrococci, 
which micrococci also existed to some extent in the spinal cord, where 
they appeared to have set up an acute myelitic process. 

Further, a series of symptoms like those of Landry's paralysis have 
been produced by inoculations of microbes from typhoid-fever spleen 
and other sources. Oettinger and Maresco in a Landry's paralysis after 
variola detected streptococci in the cells and blood-vessels of the spinal 



550 



DISEASES OE THE NERVOUS SYSTEM. 



cord. Albu failed to find any organisms in a case of alleged ascending 
paralysis, in which, however, there was no enlargement of the spleen. It 
is most probable that Landry's paralysis comprises several diseases, and 
among them an infections myelitis in which death may occnr before the 
changes of the spinal cord have gone far enough to be recognized. 

Symptomatology. — Ascending paralysis may come on abruptly dur- 
ing apparent health, or be preceded by malaise and paresthesia. The 
first distinct manifestation is a feeling of numbness and weight in the 
feet, soon followed by loss of power, which with the numbness rapidly 
increases until in a few hours the subject cannot stand. The paralysis 
continues to increase and to mount higher, involving the muscles of the 
trunk and of the upper extremities. Dyspnoea develops from the loss of 
power in the diaphragm and the respiratory muscles ; deglutition becomes 
difficult or impossible ; the voice grows feeble and inarticulate, or it may 
be suppressed ; and death results from paralytic asphyxia in two or three 
days. As the paralysis ascends it involves all the muscles in its course, 
but the muscles of the face and eyes are rarely attacked, probably because 
death occurs before they are reached. Intelligence and consciousness are 
preserved until the last. The sensory symptoms consist of a slight feeling 
of numbness, with perhaps dulling of sensation. The sphincters are not 
affected, unless it be very late in the disorder. The reflexes suffer with 
the motor paralysis. The muscles do not undergo changes in bulk or in 
their relations to electrical currents. 

Since enlargement of the spleen was first noted by Westphal it has 
been frequently found, and it is probably a constant symptom in one 
form of Landry's paralysis. Enlargement of the lymphatic glands is also 
present in a majority of cases. Absence of marked fever appears to be 
a characteristic of the disease, although distinct elevation of temperature 
has been noted. Cases have been reported of alleged Landry's paralysis 
in which the medulla was the first part of the cord to be attacked, so that 
speech, deglutition, and respiration were primarily affected. It is, how- 
ever, very doubtful whether these cases should be considered as instances 
of the disease. 

Diagnosis. — From acute central myelitis, and also from ordinary 
multiple neuritis, Landry's paralysis is distinguished by the absence of 
disturbances of sensibility, of trophic changes, of alterations of the 
electro- muscular contractility, of high fever, and of early paralysis of the 
sphincters, as well as by the rapid loss of the reflexes. Cases have been 
reported in which a neuritis confined to the motor roots has been said 
to have caused symptoms scarcely to be distinguished from those of 
ascending paratysis. 

The enlargement of the spleen and of the lymphatic glands should 
always be carefully examined for. If both are absent, the case probably 
represents some form of the disease different from that in which these 
parts are enlarged. It is possible that various poisons may induce similar 



DISEASES OF THE SPINAL COED. 



551 



spinal symptoms, and there is plausibility in the theory that ascending 
paralysis following severe exposure is of rheumatic origin. 

Prognosis. — The prognosis is always very grave. In rare cases arrest 
of the ascent takes place and recovery results. 

Treatment. — Absolute rest, careful feeding, symptomatic treatment, 
and the free use of the extract of ergot in the hope of diminishing spinal 
congestion, constitute about all that can be safely done in Landry's paral- 
ysis. If a case should present itself having arterial excitement, venesec- 
tion might possibly be justified ; while the very free use of salicylates 
would be called for by a strong suspicion of rheumatic origin. 

ACUTE MYELITIS. 

Definition. — An acute inflammatory affection, involving the whole 
thickness of the cord and producing paralysis of motion and sensation, 
with trophic changes. 

Etiology. — Acute myelitis is most frequent between the twentieth 
and the fortieth year of life, and occurs more often in men than in women. 
It may be of infectious origin, and, probably in this way, occasionally de- 
velops in chronic tuberculosis, in chronic syphilis, and in the puerperal 
state. It may be induced by traumatism and by inflammatory diseases 
of the parts immediately adjacent to the cord. Sexual excesses, unnatural 
coitus, and violent bodily exertion are assigned causes. That the com- 
bination of excessive physical exertion with exposure will produce it is 
indicated by the large number of cases which have occurred among sol- 
diers during winter campaigns. 

Morbid Anatomy. — The myelitic cord may be completely diffluent, 
or it may be soft, yielding a reddish-yellow or brownish and, to the naked 
eye, structureless section. Any portion of the cord may be attacked, but 
the dorsal cord is especially liable. The whole thickness may be com- 
pletely disorganized, but the gray matter in most cases is the centre of 
attack : hence the term central myelitis. Not rarely the disease takes the 
form of small foci scattered through the cord, constituting insular or dis- 
seminated myelitis. Rupture and necrosis of capillaries, and even of large 
blood-vessels, give varying brownish or reddish tints to the tissue, or 
give origin to small blood- clots (hemorrhagic myelitis). The line between 
sound and diseased tissue is never abrupt, the latter always shading into 
the former. When, however, the acute disease passes into the chronic 
condition the neurogliar tissue around the focus of inflammation under- 
goes hyperplasia and sclerosis, so that the focal debris is shut off and may 
finally be absorbed, leaving the sclerosed tissue as a thick-walled cyst. 
The nerve elements in acute myelitis suffer rapid degeneration. The 
multipolar cells become irregularly swollen, with their processes broken 
and shrunken, their structure coarsely granular, or in later stages form- 
less, and finally break up into debris. The nerve-filaments first enlarge 
and have their axis-cylinders especially thickened, then they become mo- 



552 



DISEASES OF THE NERVOUS SYSTEM. 



niliform, and finally they break up. In the end the myelitic tissue consists 
of debris, with remains of nerve cells and filaments mixed with drops and 
masses of myelin, large granular corpuscles, pigmented granules, altered 
blood-corpuscles, etc. Gray myelitis, so called, is the condition in which 
there has been an attempt at recovery with absorption of debris, and the 
formation of connective tissue passing into sclerosis. Under no circum- 
stances is there any repair of damaged nerve-filaments. 

The general myelitic process is commonly viewed as inflammatory, and 
as consisting of three stages : first, hyperemia and exudation (red soften- 
ing) ; second, fatty degeneration and resorption (yellow softening) ; third, 
terminal stage (cysts, sclerosis, etc.). Some authorities, however, deny 
that myelitis is in truth an inflammation ; while Spitzka affirms that 
there are no records in literature to show that there is a primary stage 
of congestion and leukocytal inflammation. 

Symptomatology. — Fever usually ushers in an attack of acute mye- 
litis, but may be entirely absent even in a fatal case. It also may rapidly 
subside, but usually persists without the temperature rising above 101° 
or 102° F. In some cases there are irregular paroxysms of intense fever, 
whilst a great rise of temperature is not a rare precursor of death. The 
spinal symptoms are : first, those of irritation ; second, those of paralysis. 
The symptoms of irritation belong to the earliest stages of the disease, and 
are usually soon lost, in some cases to reappear when partial convales- 
cence develops. They consist of twitching of the muscles, tonic or clonic 
contractures, exaggeration of the reflexes, tingling, numbness, violent 
formication, shooting pains, excessive distress during micturition and 
defecation ; even after a complete abolition of sensibility violent pain may 
be left, constituting a true anwsthesia dolorosa. The suffering may be in- 
tense, with bitter complaints of a burning girdle of molten iron, a thrust- 
ing of heated needles through the limbs, a drawing or tearing of muscles 
from the body, etc. Excessive sensitiveness of the spinous processes, 
especially to hot or cold applications, is not rare. True hyperesthesia is 
not common, but a peculiar, diffused, painful, vibrating sensation may in 
the early stages be produced by touching a part (dysesthesia of Charcot). 
True sexual excitement is never present, but painful priapism may last 
even into the paralytic stage. Complete motor and sensory paralysis, 
with flaccid muscles and loss of all reflexes and of power over the sphinc- 
ters, marks the paralytic stage. Usually, but not always, the paralysis is 
in the form of a paraplegia. The upper portion of the cord may be in the 
first stage whilst the lower is in the second stage of the disease, so that 
the symptoms of irritation will be present in the upper portion of the 
body whilst below all is paralyzed. Vaso-motor paralysis may show itself 
in a temporary rise of temperature in the paralyzed parts, but the affected 
extremities soon grow cold and bluish, and are often swollen by a diffused 
oedema. The excretions rapidly become abnormal ; even after two days 
the urine may be highly alkaline, bloody, muco-purulent, and loaded with 



DISEASES OF THE SPINAL CORD. 



553 



the crystals of triple phosphates, whilst the perspiration is excessive, 
irregular, and altered in quality. Muscular atrophy, with reaction of 
degeneration and finally complete loss of electro-contractility, appears 
very early. The trophic bed-sore, decubitus acutus, usually attacks the 
sacro-gluteal region, but occasionally appears in the heels or other portions 
of the body. The first warning consists of one or several dark-red or 
violet erythematous patches, variable in extent and irregular in shape. 
Within twenty-four or forty-eight hours reddish or brownish vesicles or 
bullae form in the central portions of the erythema. In rare cases, under 
careful management, the blebs wither and disappear without farther 
symptoms. Usually, however, the elevated epidermis drops off, leaving 
a bright-red surface with bluish or violet points or patches, and with 
swelling and sanguinolent infiltration of the surrounding tissue. Quickly 
the reddish surface becomes blackened, and a slough of variable extent 
forms. The whole buttock may thus melt down in the course of a few 
hours. Sometimes the process is arrested and the slough separates, but 
offcener the process continues, and, unless the patient dies too quickly, the 
deeper muscles, with the nerve-trunks and arterial branches, are laid bare, 
and finally the bones themselves are exposed. 

In acute myelitis the vision is not usually affected, but when the disease 
is situated very high up in the cord irregularities of the pupil and even 
strabismus may be produced j whilst contraction of the field of vision, 
amblyopia, and amaurosis have been recorded as results of complicating 
optic neuritis. 

Acute myelitis varies indefinitely in the rapidity of its course, but for 
the purposes of discussion we may recognize three types, with the under- 
standing that they grade one into the other. 

Foudroyant or explosive myelitis {myelitis centralis) commences abruptly, 
reaching in a few moments or hours the stage of paralysis, with complete 
anaesthesia, loss of motor power, abolition of reflexes, and trophic changes. 
This form of myelitis may occur without violent constitutional symptoms, 
especially when there is hemorrhage into the cord (hcematomyelitis) with 
its almost abrupt paralysis. Usually, however, there are more or less 
intense fever, delirium, coma, and even convulsions. Death may occur 
in one or two days from paralytic asphyxia, or the fatal termination may 
be reached in from one to two weeks from sepsis due to decomposing 
urine and sloughing bed-sores. 

In the type of acute myelitis may be placed those cases in which the 
paralysis requires from one to two weeks to become complete. Disturb- 
ances of cerebration are much less common than in the explosive disease, 
and death from septic fever and exhaustion may be delayed from one to 
several months, or occasionally an imperfect recovery may be secured. 

In the type of subacute myelitis may be placed those cases in which 
more than two weeks are required for a full development of the paralysis, 
or in which the palsy never becomes complete. These cases may end in 



554 



DISEASES OF THE NERVOUS SYSTEM. 



death , but more frequently they pass into chronic myelitis, with partial 
paraplegia, which may last for years or be even imperfectly recovered 
from. 

Varieties of myelitis are sometimes described corresponding to the seat 
of the disease. Of these we shall notice only myelitis cervicalis, in which 
the muscular atrophy is confined to the arms, whilst the legs are in a con- 
dition of spastic paralysis, both arms and legs being anaesthetic. Oculo- 
motor symptoms are also common, whilst dyspnoea and rapid death may 
result from paralysis of the respiratory muscles. When the cervical mye- 
litis is produced by a traumatism the patellar reflexes are primarily lost, 
but, according to the general teaching of authorities, return. Bastian, 
however, affirms that this is incorrect, and that if in any case the reflexes 
are not entirely and permanently lost it may be certainly diagnosed that 
the injury to the cord is not transversely complete. 

A myelitis may be transversely incomplete, when the anaesthesia and 
to a less degree the motor paralysis will also be incomplete. 

In a form of myelitis which follows small-pox, measles, and other in- 
fectious diseases, in which the lesion consists of very minute foci scattered 
through the whole of the nerve-centres from the pons to the cauda equina, 
the chief symptoms are disturbances of speech, tremors, and weakness, 
with an ataxia so pronounced that the affection has been spoken of as an 
acute ataxia. 

Diagnosis. — For the diagnosis between myelitis and Landry's paral- 
ysis, see page 550. Myelitis is distinguished from acute poliomyelitis by 
the presence of pain, by the muscular spasms in the early stages, and by 
the trophic changes in the skin and cellular tissue. From peripheral 
neuritis myelitis is to be distinguished by the intensity and the rapidity 
of development of its paralytic phenomena, and by the muscular atrophy 
and other changes, as well as by the absence of tenderness of the nerve- 
trunks. In subacute myelitis trophic changes may occur very slowly, 
but the nerves are not tender, and the severe, continuing, localized pains 
of neuritis are wanting. 

Prognosis. — The course of myelitis is almost uniformly in proportion 
to the original severity and extent of the symptoms. Even the mildest 
case is, however, very serious, and usually ends in some disability. 

Treatment. — If the theory be correct that acute myelitis is an inflam- 
mation, the strenuous use of venesection, cold, and other antiphlogistic 
measures is justified by the danger of the disease. There seems to be, 
however, no weighty clinical evidence to prove that these measures have 
distinct influence upon the development of the disorder. Nevertheless, 
if the general constitutional condition be good, blood may be drawn from 
the arm, and active blood-letting by means of leeches or dry cups be prac- 
tised, as is advised by many authorities. Ergot may be employed for the 
purpose of diminishing congestion, and, if not effective, certainly is harm- 
less. In the beginning it may be given hypodermically, and afterwards 



DISEASES OF THE SPINAL CORD. 



555 



from ten to fifteen grains of the official extract should be administered 
every three hours until gastric disturbance, ergotic coldness of the sur- 
face, or the continued progress of the disease indicates its withdrawal. 
The production of diaphoresis by the hot bath or the hot pack is espe- 
cially recommended by Erb when the premonitory signs of myelitis ap- 
pear directly after exposure to cold ; but the reputation of these measures 
probably largely rests upon the relief which has been obtained in cases in 
which rheumatic pains and general muscular soreness have been mistaken 
for the precursors of myelitis. 

During an attack of myelitis the warm bath is very grateful to most 
patients, and should always be tried. In employing it, absolute precau- 
tions must be taken that the patient himself make no effort whatever, a 
sufficient number of nurses to lift him being provided. The temperature 
of the bath should be in the beginning 90° F., to be increased later if it 
be found advisable. The duration of the bath should at first be about ten 
minutes, but it should be rapidly increased almost indefinitely, according 
as it is found to agree with the individual case. The bath may be given 
once, twice, or three times in the twenty- four hours. 

The very active administration of mercury, as recommended by some 
writers, seems to us of doubtful advisability, and, whilst it may be well 
to give calomel in small, repeated doses, the practitioner should content 
himself with the slightest ptyalism. Strychnine, which has been recom- 
mended by authorities, has in our experience increased the symptoms ; 
and on theoretical grounds it does not seem to be indicated. There is 
not the slightest reason for supposing that belladonna, derivation to the 
intestines, or the production of diuresis by means of the ingestion of large 
quantities of alkaline waters, as recommended by Erb, is of any service 
whatever. Of course, if excretion fails from want of nerve-influence, 
care should be exercised to see that the emunctories are kept active. 
The local application to the spine of long, thin rubber bags containing 
ice may be of service, and probably "is never injurious. Counter-irrita- 
tion by means of the actual cautery or the blister has been largely prac- 
tised, and is strongly commended by some writers. The grave danger, 
however, of developing ulcers and wide-spread gangrene attends the use 
of remedies of this class, and certainly no counter-irritants should be 
applied to the skin which is already distinctly anaesthetic, or to a part 
which may be exposed to continuous pressure. Spitzka, on theoretic 
grounds, believes that counter-irritants applied to the lower legs and the 
feet are of much more service than when applied to the back. The use 
of the galvanic current, as occasionally practised, seems to be an outcome 
of a childish credulity. 

The nursing during myelitis should be of the most careful character. 
From the very beginning, so soon as there is any reason to suspect the 
existence of the disease, rest in bed of the most absolute character should 
be prescribed. The feeding, the making of the personal toilet, etc., 



556 



DISEASES OF THE NERVOUS SYSTEM. 



should be done by an attendant. A total abstinence from muscular move- 
ments should also be enjoined, even after symptoms of convalescence 
have appeared. At such time even the least muscular exertion may 
produce a relapse. If recovery occur, the avoidance of muscular fatigue 
and of sexual intercourse for one or two years after the attack should be 
strictly enjoined. 

As the dorsal decubitus is believed by some authorities to increase 
congestion of the spinal cord, the patient should be kept as much as can 
be upon the side, or, better, if he can be made comfortable, upon the 
face, so as to remove all pressure from those portions of. the body which 
are most prone to the development of gangrenous lesions. The greatest 
care must be exercised to prevent, if possible, bed-sores : hence the but- 
tocks and the heels must be guarded from pressure, and the surfaces 
must be kept perfectly dry. The patient should always be put upon a 
water-bed, so covered with one or more heavy woollen blankets as to 
avoid any chilling of the body. All irritating applications to bed-sores 
must be avoided, and antisepsis should be carried out as thoroughly as 
may be without too much interference with the part. 

From the first hour of a myelitis the strictest attention must be paid 
to the bladder, as urinary retention, with its concurrent cystitis and pye- 
litis, is a most serious complication. In most cases continuous catheter- 
ization and irrigation of the bladder once in the twenty-four hours with 
a solution of boric acid or other weak antiseptic solution may be prac- 
tised. In all handling of the parts, as in catheterization, strict attention 
should be paid to antisepsis. The soft, flexible rubber catheter should 
be employed. It may be retained by adhesive straps, or preferably, as 
suggested by Spitzka, by using a perforated condom fixed to the catheter 
and then fastened to an inguinal bandage. To the catheter should be 
attached a soft rubber tube ending in a urinal. The condition of the 
bowels should always be attended to, mild laxatives being employed and 
aided occasionally by stimulating injections. 

CHRONIC MYELITIS. 

Definition.— Chronic inflammation of the spinal cord, involving to a 
greater or less degree its transverse section for a considerable length of 
the cord. 

Etiology. — Chronic myelitis may originate in an acute myelitis or 
be chronic from the beginning. The causes indicated are traumatism, 
exposure to cold, sexual excesses, syphilis, propagation of irritation from 
peripheral nerves, and diseases of the blood-vessels. 

Morbid Anatomy. — In chronic myelitis the cord is usually some- 
what hardened. There appear to be two distinct forms of structural 
alteration. In rare cases the whole body of the cord is filled with mod- 
erately large neuroglia- cells, pressing upon and destroying the nerve- 
elements, but showing little or no tendency to the formation of fibres. 



DISEASES OF THE SPINAL CORD. 



557 



Such cords in our experience yield a section which is reddish to the 
naked eye. 

A more usual change is a sclerosis which yields a smooth, grayish, 
or yellowish-gray section, constituting one of the conditions which have 
been called gray degeneration of the cord. Such a cord contains an 
excess of neuroglia-cells, many of them enlarged and furnished with pro- 
liferated nuclei and numerous processes (the so-called Deiters's cells), 
but it is especially composed of wavy, fibrillated bundles of fibres. The 
nerve-fibres are swollen, often irregularly so, with sheaths and axis-cylin- 
ders abundantly and irregularly enlarged, or they are atrophied, with 
destruction at first of the medullary sheath and afterwards of the naked 
axis-cylinder. The ganglia-cells are variously altered, clouded and 
swollen, or more frequently atrophied, shrunken, indurated, strongly 
pigmented, or finally changed into irregular, unrecognizable structures. 
Among the nerve- elements can usually be seen granular corpuscles, cor- 
pora amylacea, and pigment granules, whilst the walls of all the blood- 
vessels are enormously thickened and the perivascular spaces crowded 
with ce]ls and exudate. 

The membranes are commonly in a state of chronic inflammation, and 
the nerve-roots are frequently in a condition of neuritic atrophy. 

Symptomatology. — In primary chronic myelitis the onset is usually 
very insidious and marked by fluctuations. Slight sensory disturbances, 
paresthesia, partial anaesthesia, girdle sensation, loss of endurance, 
especially in walking, and uncertainty of gait may develop so slowly 
and with so many remissions that the subject scarcely knows from 
what time to date the beginning of his disorder. Constipation, loss of 
sexual power, and vesical weakness may be among the earliest symp- 
toms. 

In the fully developed disease the chief complaint is usually a loss of 
power, depression of function predominating over irritation. Violent 
pains and muscular spasms are not common, although very frequently the 
legs draw up in the bed or suffer from vibratile contractures, especially 
at night. The muscles are usually rather stiff than relaxed, and occa- 
sionally when the patient can walk the spastic gait of lateral sclerosis 
is present in a moderate degree. The reflexes are in the early stages 
of the disease almost invariably exaggerated. Often this exaggeration 
is very marked, the slightest touch upon the patellar tendon, tickling 
of the soles of the feet, or even stroking of the thighs, provoking not 
only local muscular contractions, but also general wide-spread move- 
ment. Ankle-clonus may be present. In the later stages of the affection 
the reflexes may be diminished or even entirely lost, but this rarely hap- 
pens until the gray matter of the cord is disorganized, so that loss of the 
knee-jerk is almost invariably associated with atrophy of the muscles or 
other trophic change which belongs to the last stages of the disease. 

Vesical weakness or paralysis, with retention or dribbling of the 



558 



DISEASES OF THE NERVOUS SYSTEM. 



urine, is almost universal, and is very liable to produce a paralytic cys- 
titis, which, creeping up the ureter and involving first the pelvis and 
then the secreting structure of the kidney, may end in a fatal renal 
degeneration. 

Diagnosis. — Chronic myelitis is distinguished from the subacute dis- 
order chiefly by the slowness of its development. Locomotor ataxia and 
other spinal tract diseases develop more slowly than does chronic myelitis, 
and are further distinguished by their not involving simultaneously all 
the functions of the cord, as does myelitis. 

Prognosis. — During the very slow, prolonged course of chronic mye- 
litis the general health and the bodily nutrition of the patient may be 
well preserved, provided cystitis or renal complications can be avoided. 
Complete recovery is rare, but arrest of the disease and partial recovery 
may happen. 

Treatment. — We do not believe that drugs have any direct influence 
on the progress of chronic myelitis. Silver nitrate, at one time much 
used, has been in our experience inefficient. Potassium iodide we have 
never seen do good. Large doses of mercury are not to be thought of, 
but the long- continued administration of the tonic dose of corrosive 
sublimate (one-sixtieth of a grain three times a day) may be useful. 
Counter-irritation is of doubtful value ; to have any influence it must be 
severe. The actual cautery may be applied over a considerable extent 
of the affected cord, with such light touches as only to destroy the epi- 
dermis. If the part have been previously frozen, the pain of the appli- 
cation will be trifling ; whilst the after-pain is usually not so severe as 
that of the blister. The Paquelin cautery may in this way be used every 
ten days, or as often as the part heals. Hot baths or hot packs at short 
intervals, especially hot packs to the legs, are thought to be of service. 
Electricity is rarely, if ever, directly useful, but may sometimes be used 
locally to prevent wasting of the muscles. 

The hygienic treatment is exceedingly important, and by change of 
air, careful selection of diet, and all other means, the general health 
should be improved as much as possible. Mental depression, over- 
exertion, and fatigue are to be sedulously avoided, and as favorable a view 
of the case as possible should be given to the patient. Best on the bed 
or couch is often of the greatest service, and when conjoined with daily 
use of massage may be maintained for a length of time without endan- 
gering the general health or producing muscular relaxation. When 
circumstances favor it, the patient may with great advantage spend a 
large portion of his time on the bed, couch, or lounge in the open air. 

COMPRESSION MYELITIS. 

Definition. — A myelitis due to pressure from a tumor or from dis- 
placed or diseased vertebrae. 

Etiology.— Compression myelitis may be produced by any form of 



DISEASES OF THE SPINAL CORD. 



559 



tumor or by traumatic injury to the vertebral column, but in the great 
majority of cases is the result of Pott's disease. 

Morbid Anatomy. — After death the affected part of the cord is 
found sometimes softened, sometimes hardened, with changes in it simi- 
lar to those which have been described in acute and chronic myelitis, 
but localized in a very small segment of the cord. It is asserted of this 
form of myelitis that it is entirely possible for nerve-tubules which have 
undergone more or less complete destruction to be restored. Certain it 
is that after the paralysis has been complete or nearly so for many 
months, or even, as in one case recorded by Charcot, for two years, 
the spinal cord has recovered its functional power, and also that in such 
cases the cord has been found reduced to about one-third of its normal 
volume at the point of compression, although containing an abundance 
of perfect nerve-tubules. Babinski has proved that compression of the 
spinal cord may give rise to a paraplegia very intense and even com- 
plete, lasting for months, without causing any appreciable lesion in the 
cord. 

As it does not seem probable that spinal nerve-fibres once destroyed 
can be regenerated, the most plausible explanation of the cases of re- 
covery is that the paralysis has been largely due to compression of 
nerve-fibres still intact, and that although many fibres may have been 
destroyed by the myelitis, yet enough have been left to carry on the 
function of the cord when the pressure was removed. 

Symptomatology. — The symptomatology of compression myelitis 
may be divided into those symptoms which are due to the disease pro- 
ducing the compression and those which are due to the myelitis. In 
many cases, especially in Pott's disease, nerve-roots become involved in 
the original disease, so that violent neuritic pains, trophic changes, 
anaesthesia, etc., form a part of the symptoms, not of the myelitis, but 
of the complicating neuritis. These pains usually precede the onset of 
the myelitis. The symptoms due to the myelitis itself are progressive 
paralysis of sensibility and of motion in the parts below the lesion. If 
the original lesion be of such character as first to involve one side of 
the cord more than the other, the paralytic symptoms may be to some 
degree unilateral. The patellar reflexes are usually preserved, or even 
exaggerated. Weakness of the bladder deepens into complete paralysis, 
while a similar condition of the intestines and rectum is often a very 
troublesome symptom. 

Diagnosis. — Compression myelitis is to be especially distinguished 
from an ordinary myelitis by noting its localized character and the pres- 
ence of the compressing lesion. In view of the results obtained by 
Babinski, it seems impossible to state early in a case with certainty 
whether the loss of function is produced by a severe myelitis or simply 
by compression. The more profound and persistent the symptoms the 
greater the probability of serious inflammatory changes in the cord. 



560 



DISEASES OF THE NERVOUS SYSTEM. 



Prognosis. — The prognosis of compression myelitis depends entirely 
upon the nature of the lesion which produces it. "When this lesion 
is removable the prognosis is usually good. It is remarkable how the 
spinal cord in cases of Pott's disease will so adapt itself to the narrow 
channel finally formed for it that, generally, if the bone-disease be re- 
covered from, the myelitis can be cured, even though the deformity be 
great. 

Treatment. — The treatment of compression myelitis is largely the 
treatment of its cause. In cases of myelitis due to Pott's disease the 
systematic use of the cautery is advised by Charcot. The head of a 
Paquelin cautery should be applied as a series of points on each side 
of the gibbosity of the back, the application being repeated as soon as 
the parts have healed. 

In recent cases of fracture, when there is reason to suspect pressure 
from dislocated portions of the bone, spinal trephining is a proper 
remedy. In most cases of Pott's disease it appears to us to be an un- 
justifiable procedure. In cancerous tumors surgical interference is im- 
proper, but where a morbid growth is neither cancerous, tubercular, nor 
syphilitic, and can be accurately located, an attempt at removal may be 
made. 

ACUTE POLIOMYELITIS. 

Definition. — An acute degeneration of the ganglionic .cells in the 
anterior horns of the spinal cord, characterized by paralysis and trophic 
wasting of the affected muscles. 

Etiology. — Acute poliomyelitis may occur in an adult, but is essen- 
tially a disease of childhood, five-sixths of the cases developing in chil- 
dren under ten years of age. It is not hereditary ; indeed, it appears not 
to occur with abnormal frequency in neuropathic families. It attacks 
males more often than females. According to Wharton Sinkler, it is 
more frequent in summer than in winter, at least in the Middle United 
States. The attacks appear in many cases to have been precipitated by 
over-exertion, especially by over- walking in very young children. Trau- 
matism, difficult dentition, and acute exanthematous diseases are all 
credited as occasional exciting causes. The frequency of the disease in 
childhood seems to depend upon the fact that at this period of life the 
trophic centres are forced not only to maintain the nutrition of the mus- 
cles, but also to develop their structure, so that they (the trophic centres) 
are continually in a state of hyperfunctional activity, with a consequent 
hyperemia, and are therefore easily thrown over the line of health into 
an inflammatory condition. 

Morbid Anatomy. — Degeneration of the multipolar ganglion-cells 
of the anterior cornua of the spinal cord is the essential lesion of ante- 
rior poliomyelitis. Two theories are in vogue as to the nature of these 
lesions : one attributes the changes to a primary idiopathic atrophy of 
the ganglionic cells ; the other teaches that the cells are not affected 



DISEASES OF THE SPINAL CORD. 



561 



primarily and apart from the other gray matter, but are involved in a 
limited central and focal myelitis. 

The rarity of death in the very early stages makes the post-mortems 
but few; nevertheless, Drummond, Biesler, Kahlden, and Goldscheider 
have reported cases in which death occurred within a few hours or a few 
days. 

Usually the parts immediately around the ganglionic cells have been 
affected, but in two cases very pronounced alteration has been found in 
the ganglionic cells with a nearly normal condition of the interstitial 
tissue. It has been further noted that the degree of change in the gan- 
glionic cells is not proportionate to the amount of alteration in the 
surrounding tissue : so that, whilst it may be considered settled that 
in most cases the neuroglia is attacked, it would seem clear that the 
primary and chief lesions are in the cells themselves, and that therefore 
the disease is essentially an acute poliomyelitis, in which the tissue in 
the neighborhood of the ganglion- cells is usually but not always in- 
volved. The first change in the cells is a granular opacity, which may 
be accompanied by pigmentation. This is followed by disappearance of 
the processes and shrinking of the cells, with in many cases a change of 
the protoplasm into a clear substance which refuses stains 5 at the same 
time the nuclei become pale and disappear. More and more the cells be- 
come shrunken, irregular, ball-like, and finally they cannot be recognized. 
The neurogliar tissue is usually congested, the blood-vessels dilated, with 
their lymphatic sheaths infiltrated with leukocytes or surrounded by 
minute extravasations of blood. Bound granular cells also occur in the 
neuroglia, nerve-tubes break up, myelin escapes, and finally there may 
be such general disintegration as to cause minute patches of red soft- 
ening. The cells are attacked in foci ranging in length from one-hun- 
dredth of an inch to more than an inch. In a focus the destruction may 
be limited to certain groups of cells, or may attack all the groups. 

In old cases of poliomyelitis the affected portion of the spinal cord is 
often shrunken, with the ganglionic cells entirely absent, and the nerve- 
tubules in the white columns wasted, stripped of their myelin, often with- 
out sheaths, surrounded by hyperplastic neuroglia or by amyloid bodies. 
The anterior nerve-roots suffer from an atrophy similar to that which fol- 
lows section of the peripheral nerve. The motor nerve-trunks undergo a 
change, which, as shown by Leyden, may consist of a degenerative atrophy 
or of a neuritis. Changes in the white matter of the cord and also those 
in the nerve-roots are either trophic or due to a propagation of the in- 
flammation by physiological or anatomical continuity of structure. As 
certain metallic poisons, such as lead and arsenic, are capable of pro- 
ducing an isolated neuritis or an isolated poliomyelitis, or a combination 
of the two diseases, it would appear that either poliomyelitis or neuritis 
may exist by itself, but that in some cases both affections are simulta- 
neously developed. The walls of the arterioles may be so thickened as 

36 



562 



DISEASES OP THE NERVOUS SYSTEM. 



almost to obliterate their lurnina, the change extending into the compara- 
tively normal portion of the cord. 

Symptomatology. — Acute poliomyelitis is rarely nshered in by pro- 
dromes, and may be not only sudden in its onset, but without constitu- 
tional symptoms, the child awaking after a good night's rest paralyzed, 
or with almost apoplectiform abruptness developing weakness during the 
daytime. In most cases, however, there is a primary fever of moderate 
intensity, lasting from a few hours to three or four weeks, and in rare 
instances reaching a maximum temperature of 104° F. There is great 
variability in the cerebral condition ; there may be no disturbance, or 
only an apathy which in a series of cases grades through stupor, then 
into coma ; whilst the restlessness or isolated spasms present in some 
cases pass in others into convulsive twitchings, increasing in intensity to 
the fiercest of general convulsions. Pains in the back and in the limbs 
are usual, but are seldom intense. Anaesthesia and hyperesthesia are 
so rare that their existence challenges the diagnosis. Vomiting may be 
present, and in some cases is very violent and intractable. The fever 
rarely lingers after the development of the lesion, but ends in an abrupt 
defervescence. 

Although the paralysis is in most cases complete before it is recog- 
nized, it probably always takes some hours for its development, as a 
rapidly progressive paresis has been frequently noted, and as still more 
often a paralysis already complete in one limb has under observation 
spread to other parts. The paralysis varies indefinitely in its extent, but 
the face, the intercostal muscles, and the diaphragm almost invariably 
escape. During the period of acute constitutional disturbance there is 
often incontinence or more rarely retention of the urine, but true perma- 
nent paralysis of the bladder never occurs. 

The subsidence of the constitutional disorder and the development 
of the paralysis are followed by a period of quiescence, which after from 
one to six weeks is succeeded by a peculiar, almost pathognomonic, re- 
gression of the paralytic symptoms. The extent of this regression varies 
so much that there is little relation between the final result and the 
amount of original paralysis. The improvement occasionally ends in 
complete recovery, but in the majority of cases after two or three months 
spontaneous amelioration ceases and some of the muscles settle into per- 
manent paralysis. 

During the second stage of the disease there is complete relaxation 
and loss of the reflexes in the affected muscles, with a rapidly progressive 
atrophy which is especially pronounced in those muscles which are to re- 
main paralyzed, and is accompanied by changes in the relations of the 
muscles to electricity similar to those which follow division of a nerve. 
At first the change is simply modal, — i.e., the muscle responds more slug- 
gishly to galvanic currents than it normally does. Very soon, however, 
qualitative as well as quantitative changes appear. In order to detect 



DISEASES OF THE SPINAL COED. 



563 



these changes the current must be brought in direct contact with the 
muscles, for if the electrode be applied to the nerve-trunk it will be 
found that the electrical reaction is diminished in quantity but not altered 
in quality. If the negative pole {cathode) of a weak battery be placed 
over a normal muscle, but not over its motor point, a strong contraction 
occurs at the closure of the circuit j when, however, the positive pole 
(anode) is placed over the normal muscle, the contraction is much less : 
in neither case is there any contraction when the circuit is broken. In 
other words, with the normal muscle and a feeble current we obtain good 
cathodal closing contraction, slight anodal closing contraction, and no 
motion whatever at either cathodal or anodal opening. When a current 
of sufficient power is used, opening contractions are produced, and the 
anodal contraction is greater than the cathodal. The " reaction of de- 
generation' ' consists merely in a more or less perfect reversal of the above 
formula. The anodal (positive pole) closure then causes a stronger con- 
traction than does the cathodal (negative pole) closure. When there is 
only a slight degree of degeneration present there is a correspondingly 
slight increase of anodal closing over cathodal closing contraction. A 
minimum degeneration would be indicated by an equality of the two 
closing contractions. 

These changes expressed by symbols are as follows : An CI C represents 
anodal closing contraction 5 An O C represents anodal opening contraction ; 
Ca CI C represents cathodal closing contraction ; CaOC represents catho- 
dal opening contraction : < represents is less than : > represents is more 
than (the point of the < being towards the lesser quantity). 

Then the formulas are : 



After the reaction of degeneration has been established the galvanic 
irritability gradually fades out. 

The fourth stage of poliomyelitis of many authors, that of permanent 
paralysis, is not a stage of the disease, but is a condition of wreck left 
by the disease. The distribution of the permanent loss of power varies 
indefinitely, but the paralysis is often in the upper extremities and is 
rarely symmetrical. Monoplegia is the most ordinary form ; paraplegia 
is rare ; crossed palsies and hemiplegias are still more infrequent. The 
affected part is limp or rigid, bluish, habitually weak, and without re- 

* In children it is often almost impossible to make practical test as to the reaction 
of degeneration. The failure of response first to the rapidly and later to the slowly 
interrupted faradic current is direct proof that trophic changes are taking place in 
the muscle, whether the action of degeneration can be brought out or not. 





AnOC =CaO C 
An CI C > Ca CI C 
An 0 C < Ca 0 C 



muscle in first stage of degeneration. 

muscle in more advanced stage of degeneration.* 



564 



DISEASES OF THE NERVOUS SYSTEM. 



flexes. When the destruction of the trophic centres is complete the 
muscles waste to a fibrous band, incapable of responding to any electrical 
current, whilst the development of the whole limb is retarded, so that 
in the growing child the extremity becomes shorter as well as smaller 
than its fellow. The trophic changes in the bone are not necessarily in 
direct proportion to those of the muscles, and the growth of the limb 
may be permanently arrested although the paralysis entirely disappears. 

Owing to the failure of the tendons and muscles to support the joints, 
these become more and more relaxed, until at last the head of the bone 
may be entirely out of its socket. Neither during the acute stage nor in 
the chronic after- condition do trophic inflammations or destructive lesions 
of the skin occur. 

As the years progress, various deformities arise in the affected limbs, 
caused by contractures, which may appear as early as four weeks after the 
beginning of the attack, but are usually late phenomena, and are situated 
chiefly in the muscles which have escaped entirely or in part. At the 
same time there is reason for believing that the interstitial development 
of fibrous tissue in the remains of muscles sometimes plays a part in the 
fixation of a joint. The original theory of Delpech, that the deformities 
are the outcome of contractions of sound muscles which have shortened 
on account of the failure of their natural opposition by antagonists, ac- 
counts for most of the deformities ; but the influence of weight upon 
joints from which has been withdrawn their natural support of muscles 
and ligaments is not without effect. Thus, the weight of the body press- 
ing on the arch of the foot, which has lost its natural stays, gradually 
displaces the bones from their normal relations until the arch is entirely 
flattened or the whole extremity distorted into some form of club-foot. 
The fact that pes calcaneus is very rare whilst talipes equinus is very 
common after infantile paralysis indicates that contractures are domi- 
nant factors in causing deformities, the talipes being due to the cir- 
cumstance that the calf- muscles are much less frequently paralyzed than 
are the anterior tibial groups. 

The deformities of poliomyelitis may affect any portion of the body. 
All varieties of club-foot, knock-knee and inverted knee, rigid flexion 
of the knees, kyphosis, lordosis, extraordinary scoliosis, subluxation of 
the thighs or of the humerus, claw-like distortions of the hands, — any 
of these may result, or the withered, shrunken limb, mobile almost as a 
rubber tube, may dangle from the trunk, an untoward memory of the past. 

Acute poliomyelitis is in the adult very rare. When it does occur 
the symptoms are similar to those seen in the child, except that vomit- 
ing is more common and more severe and cerebral disturbances are less 
pronounced, and that in the after-time there is much less tendency to 
the production of deformities. 

Diagnosis. — The positive recognition of the true nature of an in- 
cipient poliomyelitis with grave constitutional disorder may be impossi- 



DISEASES OF THE SPINAL CORD. 



565 



ble, but suspicion should be excited whenever an ephemeral fever in a 
young child does not conform in its history or in any of its manifesta- 
tions with any exanthem. The moment paresis is detected the diagnosis 
becomes plain. 

The completeness of the palsy and the rapid alteration of the electrical 
relations of the muscles, together with the absence of nerve-pains and 
nerve-tenderness, demonstrate that the case is not one of peripheral neu- 
ritis, whilst the course of the paralysis and the occurrence of febrile and 
of trophic disturbances separate the affection from Landry's paralysis. 
Moreover, the latter disease is extremely infrequent in children, whilst 
acute poliomyelitis is extremely infrequent in adults. 

Prognosis. — Death in the first stage of poliomyelitis is exceedingly 
rare, so that in regard to immediate danger the prognosis is most favor- 
able unless there be intense vital failure or implication of the muscles 
of respiration or of deglutition. No opinion should be given at this stage 
as to the probable extent and completeness of the final palsy, since there 
is no relation between the severity of the primary constitutional storm and 
the gravity and extent of the permanent disablement. Even in the second 
stage, when the paralysis has reached its maximum, the prognosis must 
be guarded, because a seemingly mild case will sometimes turn out most 
unfortunately, and a very wide- spread paralysis may clear up entirely. 
There is usually, however, in the second stage some direct relation be- 
tween the present and the final condition of the patient. 

The electrical condition of the muscles now becomes a very important 
factor in presaging the future. The earlier the change occurs the more 
serious the prospect ; and, vice versa, if after three weeks the muscles still 
respond well to the faradic current, the recovery will be rapid and com- 
plete. When in an advanced stage the muscles are unable to respond to 
any electrical current, the case is almost hopeless. When the power of 
responding to the direct or galvanic current is retained, although the 
faradic current produces no effect, the prognosis becomes hopeful in direct 
proportion to the length of time during which the paralysis has lasted. 
The longer the period that has elapsed the better is the outlook, because 
the preservation of the galvanic contractility proves that the trophic 
spinal cells have still some power, and affords ground for the hope that, 
although unable to stimulate the muscular nutrition to recover that which 
has been lost, they may still be able to hold up a muscle whose nutrition 
has been artificially restored. 

Treatment. — In a very robust child poliomyelitis, ushered in with 
violent constitutional disturbance, may be actively treated antiphlogis- 
tically, even venesection being allowable. Usually, however, the local 
abstraction of blood is the most that should be thought of, and after 
paralysis has appeared even this measure should be practised with great 
caution. 

In the second stage of the disorder authorities recommend for the 



566 



DISEASES OF THE NERVOUS SYSTEM. 



purpose of diminishing spinal congestion ventral decubitus, the con- 
tinuous application of cold by means of ice-bags along the spinal column, 
the administration of ergot, potassium iodide, and mercury, and the use 
of the actual cautery or other violent irritant ; in a word, the treatment 
of an acute myelitis. Erb and some other authorities recommend that 
the galvanic current should be applied without interruption for several 
hours daily, the positive pole being placed at the nape of the neck, the 
negative upon the lower end of the spinal cord or upon the affected 
muscle. There is, however, no good reason for believing that a galvanic 
current so applied reaches the spinal cord, and there is still less reason 
for believing that if it did reach the spinal cord it would do any good. 
In some cases the application may have a salutary mental effect upon the 
little patient and the parent. 

The treatment of the second stages of infantile paralysis should be 
chiefly expectant, but extract of ergot may be given in as large doses as 
the stomach will bear, and calomel cautiously administered ; the actual 
cautery may also be lightly but freely applied, provided the patient be 
old enough and intelligent enough for it to be used without causing 
spasms of terror. In the very young or timid, if it be decided to employ 
the cautery, ether anaesthesia should be induced without the patient 
knowing what is to be done. 

During the stage of regression medicinal treatment should be limited 
to the use of tonics and the persistent administration of very minute doses 
of corrosive sublimate, whilst the health of the patient should be built 
up in all possible ways and the nutrition of the muscles maintained by 
the use of electricity, massage, etc. 

In the fourth or permanent condition strychnine and phosphorus 
may be administered, in the hope of stimulating ganglionic repair. Ten- 
dencies to the development of deformities are to be mechanically com- 
bated and the muscles locally treated. In some instances hypodermic 
injection of the strychnine salts into the paralyzed muscle has seemed to 
do good. 

In the local treatment of the muscles three distinct measures are 
available : 

Mechanical vibratile treatment, combined with the application of 
heat (and perhaps also of a Junod's boot), by means of Zander's or some 
other similarly acting mechanism, certainly stimulates the capillary cir- 
culation and may be useful. 

Massage and passive gymnastics have the same aims as the mechan- 
ical treatment just spoken of, and are to be used when they can be com- 
manded : to accomplish anything, however, they must be employed very 
persistently as well as skilfully. It should be remembered that rubbing 
the skin by an untrained person is not massage, and does not, like that 
procedure, reach the deeper circulation : what is wanted is kneading of 
the paralyzed muscles. 



DISEASES OF THE SPINAL CORD. 



567 



Electricity has a limited value in the treatment of poliomyelitis. 
There is not the slightest reason for supposing that at any stage of the 
disorder it can affect the spinal cord or the nerve- trunk for good ; and its 
influence upon the muscles themselves amounts to nothing if the trophic 
centres have been destroyed. An improvement of the muscles is of no 
avail unless the spinal cord recover its power ; but the effect of partial 
rehabilitation of the ganglionic cells is greatly increased by maintaining 
the sensitiveness of the muscles. The application of electricity to the 
muscles may, therefore, be begun as soon as paralysis is detected, but the 
greatest caution is at this time necessary to avoid producing muscular 
fatigue or any reflex irritation of the nerve-centres. The daily seances 
should be short, and the current used just sufficient to produce feeble 
muscular contractions. For practical purposes the law formulated in 
H. C. Wood's "Therapeutics" some years since, that the current to be 
employed in cases of paralysis is that which will produce the greatest 
muscular contraction with the least pain, is sufficient as a guide in the 
selection of the current in any stage of the disease. Usually the faradic 
current fails entirely, so that the direct voltaic or galvanic current must 
be employed. In the advanced stage of the paralysis, if electricity has 
not been used, there is always hope that the amount of paralysis is greater 
than is necessitated by the condition of the cord : if the .muscles respond 
at all to the electrical current, careful treatment should be instituted. 
Even if the muscles seem at first entirely dead, two or three weeks' 
trial of treatment should be made, as such muscles have been awakened 
by electricity. 

The muscles should be immediately acted upon, one electrode being 
placed over the insertion and the other over the origin of the muscle, and 
from time to time one electrode being put on the motor point. The gal- 
vanic current may be slowly interrupted, but the effect is much greater 
if by mechanical arrangement instead of simple interruption there is a 
reversion of the current. If after eight weeks of electrical treatment no 
gain is achieved, nothing is to be hoped for. 

In all cases of infantile paralysis it is essential to prevent, as far as 
may be, the development of deformities. Contractures are to be over- 
come, if possible, whilst forming, by thoroughly stretching the muscles 
morning and evening with the hand. When the contracture persistently 
increases, section of the tendons should be resorted to. The operation is 
simple and without danger, and experience shows that the relief to the 
limb has a distinct effect upon the nutrition of the muscles. So true is 
this that after such section a renewed attempt to develop the muscles by 
electrical treatment should always be made. The application of braces 
or other appliances to the legs to aid in locomotion is often imperatively 
demanded. It is very much better for the child to exercise the limb 
even partially than that there should be added to the failing nutrition 
of spinal disease the depressing influence of loss of use. 



568 



DISEASES OF THE NERVOUS SYSTEM. 



Ascending Poliomyelitis.— In 1849 Duchenne described a peculiar 
paralytic affection whose pathology is not yet elucidated, but is probably 
that of a myelitis affecting especially the gray matter. The symptoms 
consist of a rapidly developed paralysis beginning in the legs and extend- 
ing upward, associated with complete muscular flaccidity, loss of reflexes, 
and rapidly progressive atrophy of the muscles with reaction of degen- 
eration. The affection is distinguished from simple poliomyelitis by 
its ascending progressive course, and by the absence of the stages of 
general stationary paralysis and of regression. From Landry's paralysis 
it differs in the presence of muscular atrophy with changes in electro- 
contractility. From neuritis it is distinguished by the absence of nerve 
pain and tenderness. From progressive muscular atrophy it is sepa- 
rated by its rapid course and by the fact that the paralysis precedes 
the atrophy and is attended early in the case with well-marked reaction 
of degeneration. When the disease continues to ascend, and implicates 
the muscles of deglutition and of respiration, it may cause death ; but 
in the majority of cases the patient recovers with more or less damage 
to the muscles. 

The treatment may be that of chronic myelitis, with the addition 
of local electrical treatment for the maintenance of the nutrition of the 
muscles. The resemblance of this affection to certain cases (see below) 
of chronic metallic poisoning suggests very strongly that it is due to a 
toxaemia, and that strychnine should be used. 

Metallic Poliomyelitis. — A paralysis with muscular atrophy may be 
produced by various metallic poisons, especially arsenic and lead. In the 
majority of cases it is the result of a peripheral neuritis, but it may 
occur without pain or nerve-tenderness, and probably, therefore, be due 
to a lesion of the cells in the anterior horns. The recognition of this 
variety of poliomyelitis is a matter of grave importance, because it in- 
volves the treatment. The character of a case can usually be recognized 
by attending to the following points : first, the patient is an adult ; second, 
the attack is without fever, and the paralysis is much more wide-spread 
and more slowly and progressively developed than in ordinary mild acute 
poliomyelitis ; third, the sphincters, the bladder, and the respiratory 
muscles, which are usually not affected in true poliomyelitis, are almost 
invariably attacked 5 fourth, there is usually but not always disturbance 
of sensation ; fifth, suspicion being aroused, evidences of metallic poison 
can be obtained from the history, from the presence of the blue line on the 
gums, or by finding metal in the urine. This form of metallic poisoning 
may resemble Landry's paralysis in the progressiveness of its course, 
but is distinguished by the trophic changes which occur in the muscles. 
Its treatment is that of the metallic poisoning, added to the local use of 
electricity and of massage upon the muscles, and the administration of 
massive doses of strychnine, which alkaloid we have seen when pushed 
to its furthest limit act most promptly and effectually. 



DISEASES OF THE SPINAL CORD. 



569 



CHRONIC POLIOMYELITIS. PROGRESSIVE MUSCULAR ATROPHY. 

Definition. — A disease characterized by a degeneration of the tro- 
phic spinal cells, accompanied by progressive muscular atrophy with 
loss of power. 

Etiology. — Progressive muscular atrophy is more frequent in males 
than in females, and usually develops between the ages of twenty -five 
and fifty. Heredity, and especially indirect neuropathic heredity, seems 
to have etiological influence in a majority of cases. Overwork, mental 
distress, exposure, traumatisms, and syphilis are all assigned causes, but 
their action is very obscure. 

Morbid Anatomy. — The affected muscles are pale in color, with 
various alterations in their fibres. Four of these changes seem to be well 
defined : first, narrowing of the fibres, with some indistinctness of the 
striation ; second, fatty degeneration, in which the striae become granular 
and the granules increase in size until at last the sarcolemma is replaced 
by fat-globules ; third, hyaline degeneration, in which the muscle-sheaths 
contain only a clear, homogeneous, striated material with embedded glob- 
ules ; fourth, an apparently longitudinal splitting of the fibres, with loss 
of the striation, or with an appearance of striation much finer than 
normal, followed by fatty degeneration. Of all these processes the ulti- 
mate end is an empty sheath, shrunken, but clearly distinguished from 
the interstitial fibrous tissue. 

Nerve- degeneration seems to begin in the anterior roots, and probably 
is confined to the motor fibres, so that a peripheral nerve will in the end 
contain many empty sheaths. The posterior roots remain normal. 

The primary lesion of the disease is a slow wasting of the ganglionic 
cells of the spinal cord, by which they lose their processes, become globu- 
lar or irregular in form, and, shrinking into angular masses, finally disap- 
pear, leaving foci of the gray matter in which there is no trace of cells. 
To this lesion is added, in old cases, a well- developed sclerosis of both 
direct and crossed pyramidal tracts. The nerve-fibrillae of the cord, 
which are the prolongations of the ganglionic cell processes, have usu- 
ally disappeared from the affected tissues, and probably suffer very early 
in the disease. The larger blood-vessels are often enlarged, the minute 
blood-vessels not much changed. The degeneration of the gray matter is 
in typical cases confined to the anterior horns, the posterior remaining 
normal. 

Symptomatology. — Progressive muscular atrophy is always a very 
insidious and slow disease ; in most cases the first symptom to attract 
attention is a loss of endurance, or even a loss of momentary power ; the 
muscle is found softer and more flaccid than normal, and in a short time 
the atrophy is apparent. Sometimes before the atrophy, always sooner 
or later, fibrillary contractions occur. They consist of irregular twitch- 
ings of the muscle-fibres, which produce no effect except a movement of 



570 



DISEASES OF THE NERVOUS SYSTEM. 



the skin over the contraction. They may be slow and irregular, or may 
amount to stormy peristaltic movements hurrying through the muscle 
in rapid succession. Usually their severity is in direct relation to the 
activity of the disease process. Wasting palsy usually attacks groups of 
muscles which are more or less isolated and separated from one another ; 
in the majority of cases it is somewhat symmetrical, although it is not 
exactly the same muscles on the opposite sides of the body that are 
affected. The degree of the paralysis of the muscles is in direct pro- 
portion to the loss of muscular substance, which is evidently the cause 
of the weakness. 

The hands are in most cases the first portion of the body to be 
attacked, and frequently the symptoms are more severe in the right 
than in the left hand. According to Eulenberg, the interosseous muscles 
commonly suffer first, whilst Roberts, Wachsmuth, and Friedreich state 
that the ball of the thumb is usually implicated before the interosseous 
muscles. The first external interosseous is said to be the first to feel 
the influence of the disease, whilst the opponens and the adductor pol- 
licis are more apt to suffer than the extensors, the abductors, and the 
flexors of the thumb. In the few cases in which we have had an oppor- 
tunity to see the disease in its earliest stage the interosseous muscles 
were the first affected. The loss of power in the interosseous muscles 
is especially apparent in abduction of the index finger ; whilst the 
wasting shows itself in the flattening of the thenar eminence and the 
falling in of the interosseous spaces. 

Progressive muscular atrophy sometimes makes its first appearance in 
the deltoid, in the pectoralis major, in the serratus magnus, or even in 
the lumbar muscles. The legs are the most infrequently affected, but do 
not always escape. The disease process may spread to the medulla, and 
indeed the medulla may be primarily attacked, constituting glosso-labial 
paralysis. 

The " ophthalmoplegia externa" of Hutchinson (see page 595) may 
also be a symptom of progressive muscular atrophy. 

Disturbances of sensation are never severe in a pure muscular 
atrophy, and in most cases there is either no or only very slight pares- 
thesia. 

The loss of power in the diseased muscles and the secondary con- 
tractures which occur in their antagonists produce in some patients ex- 
traordinary deformities. In one case under our care, in which the disease 
commenced, or at least very early was most pronounced, in the neck, the 
head perpetually fell forward, the chin resting upon the breast. The 
most characteristic of the deformities is the clawed hand, caused by the 
permanent flexion of the last two phalanges of the fingers, which are ex- 
tended at the metacarpal joint. As was shown by Duchenne, this de- 
formity is the result of atrophy of the internal and external interosseous 
muscles with the preservation of power by the extensors and flexors 



DISEASES OF THE SPINAL COED. 



571 



of the fingers. It must be remembered that this deformity is really 
pathognomonic of paralysis of the interosseous muscles, and is charac- 
teristic of progressive muscular atrophy only for the reason that loss of 
power of the interosseous muscle is rare from other causes. If, however, 
from local disease of the nerves the interosseous muscles be paralyzed, 
the clawed hand will be developed. If only one hand be clawed, local dis- 
ease should be suspected. Subluxation of the shoulder -joint is common in 
cases in which the muscles of the part are especially paralyzed. 

The electro-muscular contractility is remarkably preserved, evidently 
because the destruction of the trophic cells in the cord involves indi- 
vidual cells one after the other, and consequently compromises trophically 
individual bundles of muscle-fibres, one after the other, so that the 
muscle loses power not en masse, but fibre by fibre, that portion of the 
muscle which retains its functional activity remaining in health and pre- 
serving its normal electrical reaction. According to Eulenberg, in the 
later periods of the disease qualitative alteration in the muscular reaction 
may be shown by an increased reaction under anodic closure, and less 
commonly by an increase under cathodic opening. We have never been 
able to demonstrate this. Remak' s diplegic contractions are also rarely 
to be demonstrated in progressive muscular atrophy.* 

There is sometimes a heightened irritability of the muscular fibres 
in progressive muscular atrophy which causes the muscle to react more 
actively than normal to the faradic current. This condition we have 
noted especially when the fibrillary contractions were very severe. In 
some very slow cases of muscular atrophy with deposition of fatty mate- 
rial in the muscles the response to the faradic current is sluggish. 

Diagnosis. — The slow progression of the symptoms, the occurrence 
of atrophy before paralysis, the preservation of the electrical relations 
of the muscles, the absence of distinct disturbances of sensation and 
of pronounced tenderness, make the recognition of progressive muscular 
atrophy usually very easy. The only disease with which it can be con- 
founded is pseudo-hypertrophic paralysis. (See Pseudo-Hypertrophic 
Paralysis. ) 

Prognosis. — The course of the disease usually spreads over many 



* ' ' Remak found that the contractions could be produced in the atrophied muscles 
of the arm when the positive electrode was placed in an ' irritable zone, ' which ex- 
tends from the first to the fifth cervical vertebra, or, still better, in the carotid fossa 
or the triangle between the lower jaw and the external ear, while the negative was 
put below the fifth cervical vertebra. The contractions were always on the side. op- 
posite to the anode, but when the electrodes were applied in the median line they 
occurred on both sides. If the current was very weak they were limited to the mus- 
cles most severely affected. Remak regarded these as reflex contractions originating 
from the superior cervical ganglion of the sympathetic, and especially as the patient 
perceived a sensation behind the ball of the eye when the current was closed." 
(Eulenberg.) 



572 



DISEASES OF THE NERVOUS SYSTEM. 



years. Remissions sometimes occur, and it is not very rare for the 
paralysis to be long located in a few groups of muscles. 

Treatment. — In our experience the treatment of progressive muscu- 
lar atrophy has been without good result. The effect of electricity and 
massage on the muscles has not been perceptible. Gowers, however, 
asserts that arsenic and strychnine are very useful, and that he has 
known the progress of the disease to be arrested by the hypodermic 
injection of strychnine, although the drug had been given by the mouth 
without avail. The dose which he employs is very small, one injection 
a day of one-eightieth of a grain, gradually increased to one-fortieth, 
never beyond. The greatest care should be taken during the whole 
course of the disease to avoid muscular fatigue, which has a decided 
deleterious influence. Prolonged rest in bed would seem to be indicated. 

SYRINGOMYELIA. 

Definition. — A chronic disease characterized by the presence of 
cavities in the spinal cord, and by peculiar alterations in the sensibility, 
associated with motor paralysis and various trophic disturbances. 

Etiology. — Concerning the causes of syringomyelia we have no defi- 
nite knowledge. The disease usually begins between fifteen and thirty- 
five years of age ; it is more frequent in men than in women, and in 
laborers and artisans than in brain- workers ; it does not appear to be 
distinctly hereditary, although there is reason for believing that it de- 
pends upon some embryological affection of the cord which diminishes 
the power of the nerve-elements to resist the hyperplastic tendency 
inherent in neurogliar tissues. It may exist as a primary affection, but 
has been associated with lateral sclerosis, poliomyelitis, chronic perien- 
cephalitis, and other organic diseases of the brain or the spinal cord. 

Morbid Anatomy. — The principal lesion in syringomyelia is spinal, 
with secondary trophic changes in the muscles, the bones, the cellular 
tissues, the skin, and the peripheral nerves. To macroscopic examina- 
tion the cord may present the appearance of a large blood-vessel empty 
and collapsed. It is irregularly increased in size, deformed, soft and 
fluctuating to the touch, or giving the sensation of a hard, firm, rigid 
cord, and contains one, two, or rarely three cavities, situated in the 
horns of the gray matter. The size, length, shape, and cross- dimensions 
of the cavity vary almost indefinitely. Its liquid or gelatinous contents 
are enclosed by a smooth yellowish coating. 

Hydromyelia — that is, dilatation of the spinal cord with excess of 
fluid — has long been known to the profession as a pathological condition 
which may exist without producing symptoms during life ; it is probably 
the analogue of hydrocephalus internus, and is caused by a stopping up 
of the spinal canal. It is, however, rather an accidental than an essential 
part of syringomyelia, whose primary histological lesion is looked upon 
by the majority of investigators as a neoplastic hyperplasia of the neu- 



DISEASES OF THE SPINAL CORD. 



573 



roglia of the gray matter, but is believed by others to be a hyperplastic 
myelitis. According to the late researches of Hoffmann, the disease 
commences in proliferation of the epithelial lining of the spinal canal, 
and in many cases proceeds from a congenital anomaly, — viz., nests of 
embryonal tissue. The result of this proliferation is a mass, the so- 
called gliosis, which closes the central canal and after a time undergoes 
regressive metamorphosis, with destruction of the tissue and formation 
of a cavity. The gliotic tissue is composed chiefly of mono- or bi- 
nucleated, spider-like cells with long anastomosing processes, between 
which are granular elements and pigment-granules. The lining of the 
cavity is a dense fibrillary felting, which is not sclerotic. During the 
process of growth and degeneration secondary inflammations, hemor- 
rhages, and wide-spread sclerosis are produced in the surrounding tissue. 
The peripheral nerves are usually found altered, suffering from paren- 
chymatous neuritis, or perhaps from atrophy. The muscles themselves 
undergo atrophy, and Dejerine found that the intra- muscular nerves 
were normal or atrophic according as their muscles were normal or 
atrophic. The changes in the nerve and in the muscle are, however, but 
secondary lesions. 

Symptomatology. — Syringomyelia commences insidiously, with weak- 
ness and disorder of sensation in the upper extremities, followed after a 
time by muscular atrophy, with increase in the sensory symptoms j then 
by spinal curvature in the form of scoliosis ; and finally by motor palsy 
in the lower limbs. Vaso- motor and trophic changes in the skin, in the 
subcutaneous cellular tissues, and even in the joints and bones, soon 
follow upon the muscular atrophy. In some cases the shoulder muscles, 
more rarely those of the lower extremities, are first attacked, and the 
medulla oblongata may be the part primarily affected. 

The most characteristic symptom of syringomyelia is a peculiar dis- 
association of ordinary sensation. Commonly the sense of pain and the 
power of recognizing heat and cold are diminished or lost, although sen- 
sibility to touch and the muscular and special senses are intact. Earely 
it is some form of ordinary sensibility which is first lost, and cases have 
been recorded in which pain and thermic sensibility have been increased, 
ordinary sensibility remaining normal. Further, thermic sense perver- 
sion may be produced, so that hot bodies feel cold and cold bodies hot. 
The thermic anaesthesia may be so slight that it can scarcely be made 
out, or so complete that a patient can be burned without being aware of it. 

The thermo-antesthesia and the analgesia do not necessarily coincide 
in degree or position, and may from time to time vary in the same case. 
They usually occupy considerable zones, and affect both mucous mem- 
branes and skin. In some cases there are burning or freezing subjective 
pains. Loss of motor power in the arms is a common primary symptom. 
Usually motor disturbances in the legs are secondary, and develop late 
in the disorder. They commonly consist of spasmodic paraplegia with 



574 



DISEASES OF THE NERVOUS SYSTEM. 



exaggerated patellar reflexes, but may be simply ataxic incoordination 
with abolished reflexes. Loss of motion is followed in the upper ex- 
tremities by muscular atrophy, secondary contractures, and a claw -like 
hand resembling that of poliomyelitis. Paralysis and trophic disturb- 
ances are extremely common in the muscles of the neck, so that scoliosis 
is an almost constant and may be an early symptom 5 it is said to be 
almost universally dorso-lumbar, with the convexity to the left. The 
atrophic muscles may give the reaction of degeneration ; more com- 
monly, however, there is a simple diminution of electrical excitability. 

As the disease progresses, the paralysis extends up the arm, and 
finally involves the shoulder and even the face. Indeed, altered tri- 
geminal sensations, nystagmus, inequalities of the pupil, disturbances 
of the taste, paralysis of the vocal cords, dyspnoea, and rapid heart 
action, any or all of these may develop as the result of serious impli- 
cation of the medulla. 

The trophic changes in syringomyelia are very marked. The skin 
may become glossy or be covered with a thick epidermis or with bullous, 
eczematous, or herpetic eruptions. Perforating ulcers have been de- 
scribed, and in rare cases there has been a trophic gangrene of the skin, 
followed by loss of substance and by a whitish cicatrix. The distorted, 
thickened, often furrowed nails sometimes fall out. The subcutaneous 
cellular tissues may be cedematous or the seat of abscesses and especially 
of whitlows. The bones and joints sometimes undergo arthropathic 
changes similar to those seen in locomotor ataxia 5 and acromegalia, 
coinciding with, if not dependent upon, syringomyelia, has been reported. 

The implication of the vaso- motor and secretory systems is shown 
by irregular or exaggerated sweating, by blueness and coldness, or by 
swelling, scarlet color, and excessive heat of the extremities. Polyuria, 
cystitis, and even perforating ulcers of the bladder may occur. 

Various clinical types of syringomyelia have been noted. Blocq de- 
scribes two : in one the atrophy commences in the ulnar nerve distribu- 
tion and is followed by spastic paraplegia, in the other the atrophy 
begins in the radial nerve and is followed by tabetic incoordination. 
The cases vary, however, so much that no description of types is of 
value. If the gliosis attacks especially the posterior portion of the cord, 
the prominent symptoms may resemble those of tabes. Morvan's dis- 
ease appears to grade into syringomyelia through an unbroken series 
of cases, and must therefore be considered simply a variety of it. In it 
the tactile sense nearly always disappears with the other forms of sensi- 
bility ; the trophic changes predominate, and almost exclusively consist 
of multiple whitlows, deep cracks and fissures in the skin, and arthropa- 
thies of the smaller joints. Moreover, in certain cases these affections 
are symmetrical on both hands and feet, and do not attack the remainder 
of the body. Finally, the muscular atrophy is slightly marked, and is 
not, as a rule, progressive. 



DISEASES OF THE SPINAL CORD. 



575 



Diagnosis. — Syringomyelia is distinguished from cervical pachyme- 
ningitis by being much less painful and not accompanied by rigidity 
of the neck, and by the peculiar disturbances of sensation. In sclero- 
dactylitis simulating syringomyelia, sensation is preserved, whilst the 
inflammation of the skin is a dominant, not a secondary, feature of the 
case. In alcoholic paralysis thernio-ansesthetic disturbances resembling 
those of syringomyelia sometimes occur, but the symptoms usually 
appear in the lower extremities and are developed very rapidly, whilst 
tenderness of the muscles or of the nerve-trunks can be made out. The 
hysterical simulation of syringomyelia may be detected by noticing the 
presence of hysterical symptoms, the wide extent of the anaesthetic dis- 
turbance, and the absence of degenerative atrophy of the muscles. It 
must be remembered, however, that syringomyelia may develop in the 
hysterical subject. 

Prognosis. — The course of syringomyelia is very slow, usually ex- 
tending from ten to twenty years, and accompanied with marked remis- 
sions. The correctness of the assertion sometimes made that recovery 
may occur seems doubtful. Death is usually due to the spread of the 
disease to the medulla oblongata, or to exhaustion produced by cystitis, 
decubitus, septicaemia, etc. 

Treatment. — No drugs are of any value except for giving relief of 
symptoms. The bodily health should be maintained, the analgesic skin 
carefully protected from injury, and muscular fatigue and cystic compli- 
cations guarded against. Counter-irritation and suspension, as recom- 
mended by French authors, probably do no good. Electrical treatment 
of the spine is entirely without value, and even the attempt to maintain 
by electricity the nutrition of the affected muscles is hopeless. 

LOCOMOTOR ATAXIA. TABES. 

Definition. — A disease accompanied by sclerosis of the posterior root 
zones of the spinal cord, and characterized by loss of coordination and 
of the reflexes, with disturbances of sensation, but without paralysis or 
atrophy of the muscles. 

Etiology. — Locomotor ataxia is not hereditary, is much more fre- 
quent in males than in females, and is a disease of middle life, although 
it may occur at any age. In the great majority of cases it develops in 
persons who have had syphilis, coming on from five to twenty years after 
the infection. It is not, however, specifically a syphilitic disease, and 
may occur in non-syphilitics. According to the observations of Tuczek, 
a disease resembling tabes symptomatically and anatomically may be 
produced by ergotin, and it is possible that there is a post- syphilitic poison 
which produces tabes. Sexual excess is not, as was at one time taught, 
an ordinary cause of locomotor ataxia, if indeed it ever produces it. 
Overwork, nervous strain, immoderate use of alcohol and tobacco, ex- 
posure to wet and cold, peripheral traumatism, lead and other poisons, 



576 



DISEASES OF THE NERVOUS SYSTEM. 



have all been assigned as causes for the disorder, but their influence is 
very obscure. 

Morbid Anatomy. — The lesion of tabes may develop in any por- 
tion of the spinal cord, but usually is primarily lumbar ; in the advanced 
degeneration the microscope shows a mass of connective tissue with atro- 
phied axis- cylinders from which the myelin sheaths have wasted away. 
The connective tissue is fibrillated and nucleated, and excessively tra- 
beculated ; sclerotic changes are usually pronounced in the vessels. An 
early stage of the sclerosis is that in which there is increase of the nuclei 
and of the amount of the connective tissue, with wasting of the myelin 
sheaths. Westphal and some other pathologists state that preceding this 
stage can be demonstrated one of simple granular change. 

There is still uncertainty as to whether the process begins in the pos- 
terior spinal roots or in the posterior root-zones (columns of Burdach) of 
the cord. Leyden, Marie, and other authorities believe that the degen- 
eration ascends from the nerve-roots into the spinal cord, making the 
primary lesion of locomotor ataxia a degenerative neuritis, which is be- 
lieved by some to commence in the nerve peripheries and extend upward, 
— a highly improbable view. It is certain that the columns of Burdach 
are very early attacked, and that the lesion following the ascending 
nerve-bundles passes up the cord, not only along the root-zones, but 
especially into the columns of Goll, which are usually diseased higher 
up than are the root-zones. There are cases in which the columns of 
Goll seem to be more thoroughly diseased than are the root-zones. 

There are two beliefs among pathologists as to which tissue is pri- 
marily affected : some maintain that the disease begins in the neuroglia, 
and that the changes in the nerve-elements are secondary to the con- 
nective hyperplasia, whilst others affirm that the essential lesion is a 
parenchymatous degeneration of the nerve -elements, with hyperplasia 
of the connective tissue as a secondary result. Spitzka has put for- 
ward the very improbable view that there are two varieties of locomotor 
ataxia, one interstitial, one parenchymatous. 

The disease process finally affects the gray substance, especially at- 
tacking Clarke's columns, and causing atrophy of the nerve-fibres and in 
some cases wasting of the cells. As was first demonstrated by Westphal, 
the peripheral nerves habitually suffer in tabes ; the alteration is a paren- 
chymatous neuritis, and appears to be confined to the sensory filaments. 
It is most marked in the extreme periphery of the nerve, so that the 
cutaneous filaments may be distinctly altered and the large nerve-trunks 
free. The optic, pneumogastric, trigeminus, and other cerebral nerves 
are sometimes affected. The peripheral situation of the neuritis, and the 
fact that in some cases the cord lesion apparently precedes, in others fol- 
lows, the change in the nerves, indicate that the lesions of the nerves 
and of the spinal cord are not dependent one upon the other, but are 
due to some common cause. 



DISEASES OF THE SPINAL CORD. 



577 



Symptomatology. — The symptoms of locomotor ataxia are usually 
very slow and insidious, and without fixed regularity or order in their 
development. They commonly appear first in the legs, but not rarely 
double vision, giddiness, or other head symptoms take precedence, and 
the upper extremities may be for years the exclusive site of the disease. 
Leaving the course and early stages of the disease for discussion in the 
paragraphs under diagnosis and prognosis, we shall study the general 
symptoms under the heads of Disturbances of Sensation, Disturbances of 
Motion, Disorder of the Organs of the Special Senses, Trophic Changes. 

Disturbances of Sensation. — Pain is a prominent symptom in more 
than nine-tenths of the cases of tabes, and is variously described as though 
a red-hot wire or a sharp dagger were thrust through the limb. In 
some cases these so-called fulgurant pains occur continually ; in other in- 
stances they come on in paroxysms 5 but almost invariably they tempo- 
rarily disappear at intervals. They may follow the distribution of the 
nerves, but more commonly are most severe in the neighborhood of the 
joints, especially in the inside or the outside of the knee or of the ankle. 
Usually they are not associated with redness or any soreness, and often the 
patient seizes the affected part forcibly and obtains by the pressure some 
relief. A certain amount of redness and tenderness may, however, be 
present during the pain, and in very rare cases trophic eruptions occur. 
Sometimes the pain seems wide- spread and superficial, and is then usually 
spoken of as burning or more rarely as a sensation of intense cold. 

Pain crises, which are almost pathognomonic of locomotor ataxia, con- 
sist of paroxysms of excessive pain with pronounced functional disorder 
of the viscus in which they are located, but without fever. The attacks 
usually begin and end abruptly, and may last from a few minutes to sev- 
eral days. The functional activity of the organ may be at once resumed 
when the pain is over. In the height of the agony syncope or a wild 
outburst of maniacal melancholy with attempts at suicide may occur. 
The most important of the pain crises are the muscular, the gastric, the 
rectal, the urinary, the genital, the cardiac, the laryngeal, and the lym- 
phatic. 

The gastric crises, the most frequent of any, are characterized by vio- 
lent shooting and burning pains, having their focus in the epigastric 
region and radiating in all directions, laterally, upward, downward, until 
at times they seem to fill with agony the whole abdomen and chest. They 
are generally increased by epigastric pressure and by the ingestion of 
food, and are always accompanied by nausea and excessive vomiting. 
After the stomach has been once emptied the discharge is glairy or ropy, 
neutral or acid, and often streaked with blood ; rarely there is abundant 
coffee- ground vomiting or even pronounced hseniateinesis. In some cases 
the focus of the pain is in the neighborhood of the umbilicus, when the 
crises might properly be spoken of as intestinal. Occasionally large quan- 
tities of gas form in the gastro- intestinal tract and produce a very obsti- 

37 



578 



DISEASES OF THE NERVOUS SYSTEM. 



nate meteorism, or there may be copious bilious, mucous, or serous stools. 
In such cases loss of the voice, suppression of urine, extreme coldness 
and cyanosis of the body, cramps, and collapse may closely simulate 
cholera, and death may result. In the rectal crises the pains radiate from 
the rectum, or this receptacle feels as though it were filled up by an 
enormous body heated to redness, burning and scorching every part near 
it. Muscular crises are extremely rare, and consist of an excessive mus- 
cular weariness and soreness which paralyze for a time the affected 
muscles. Genital crises may consist of violent paroxysms of pain centring 
in the testicle and shooting along the penis, or, in the female, darting 
from the ovaries, boring and burning through the whole genitalia. In 
some cases spontaneous venereal orgasms occur ; at first each orgasm 
ends in a fury of voluptuous delight, but as time passes this delight 
takes on more and more the character of pain, until rapturous ecstasy is 
lost in agony. The genito-urinary crises may closely simulate renal colic ; 
usually, however, they consist of intense burning or lancinating pains 
in the urethra, associated with unconquerable cystic tenesmus. When 
there is an anesthesia of the bladder, with consequent urinary retention 
and ammoniacal fermentation, and deposits of phosphates, the symptoms 
may be strongly suggestive of calculi. 

A lymphatic crisis, as first described by H. C. Wood, consists of a vio- 
lent paroxysm of pain (accompanied with great swelling, redness, and 
tenderness) in the lymphatic glands, appearing with absolute suddenness 
and disappearing almost as abruptly, but leaving behind it an increase in 
the volume of the gland, which, if not perceptible at first, finally through 
successive crises becomes a distinct enlargement. In cardiac crises there 
are violent lancinating and constricting pains in the region of the heart, 
associated with great dyspnoea, intense distress, and irregularity of the 
pulse, with or without intermission of the heart-beats. Laryngeal crises 
consist of violent paroxysms resembling laryngismus stridulus, but asso- 
ciated with atrocious fulgurant pains in the larynx, back, and shoulders, 
and sometimes accompanied by the expectoration of little bloody pellets 
of mucus. Death from laryngeal asphyxia has resulted in these cases ; 
and when laryngeal anesthesia is present, food frequently enters the 
larynx and lungs. 

Formications and other paresthesia are common in tabes. The girdle 
sensation, a feeling as though a tight band were drawn around the head, 
the neck, the body, or the limbs, is usually very distinct. Numbness 
may develop early or late, and often when in the foot produces a sensa- 
tion of walking or standing upon velvet or upon cushions of down. The 
mucous membranes of organs in which crises occur are prone to be com- 
pletely anesthetic ; the numbness may exist without analgesia, or with- 
out paralysis of the tactile or of the temperature sense. All forms of 
sensibility are, however, in most cases sooner or later diminished. De- 
layed sensation is not uncommon, and five, ten, or even fifteen seconds 



DISEASES OF THE SPINAL COED. 



579 



may elapse between the time of the contact and its perception. It is not 
very rare for a distinct interval to exist between the perceiving of the 
contact of a sharp point and of the pain which it causes. Mendelssohn 
affirms that the normal reaction of the sensory nerve to electricity may 
be reversed, so that on closing the circuit the earliest sensation is at the 
positive instead of at the negative pole, as in health. The localizing 
power is sometimes curiously perverted : a single prick may be felt in 
many places (polywsthesia), or a prick on one leg may be located on the 
other (allocheiria). 

Motion, including Reflexes. — The cutaneous reflexes are usually at 
first unaffected or very rarely increased ; when anaesthesia exists they are 
usually diminished, but they may be lessened or even abolished without 
marked disturbances of sensation. The deeper reflexes are profoundly 
affected ; indeed, loss of the knee-jerk (WestphaVs symptom) is one of the 
earliest and most constant phenomena, but may be absent when the lesion 
is confined to the upper cord. Loss of coordination is a most charac- 
teristic symptom j closely connected with it is the so-called Romberg's or 
Brack's symptom, which may precede all other evidences of the disease, 
and always belongs to the earliest stage. It consists of a peculiar ver- 
tigo, usually associated with a momentary sense of terror, produced by 
quickly stepping from a light into a dark place, or by quickly shutting 
the eyes. 

In most cases the loss of coordination is shown by excessive swaying 
when the patient is made to stand with the feet close together or on one 
foot. If, however, this test fail, sudden turning or the attempt to walk a 
chalk line will usually succeed, and if the eyes be closed the lack of con- 
trol becomes at once manifest. Sooner or later the so-called ataxic gait 
develops. The patient walks with his head a little bent forward and the 
eyes directed to the ground. The trunk inclines upon the thighs, whilst 
the feet are held in advance of the buttocks, with the legs widely sep- 
arated from each other. At the same time, owing to the excessive con- 
tractions of all the muscles of the lower extremities, the leg proper is 
extended somewhat rigidly upon the thigh, and there is very little move- 
ment at the knee-joint. The advancing leg is therefore raised from the 
ground in some degree by an elevation of the pelvis, although at the 
same time some flexion does occur at the knee-joint. By these con- 
joint movements the foot is freed from the ground, and, having been 
flung forward and outward by a rapid muscular jerk, comes down with a 
thump like a solid mass. In some cases the heel is the last to leave the 
ground and the first to touch it. Not rarely the pelvis is so much in- 
clined during walking as to carry the centre of gravity too far towards 
the side of the stationary leg. To counteract this and maintain the 
balance of the body the upper portion of the trunk is curved towards the 
advancing leg by a contraction of the erector spinas muscles, or the arm 
corresponding to the advancing leg is thrust out laterally. The alterna- 



580 



DISEASES OF THE NERVOUS SYSTEM. 



tion of these movements at each step may give a pendulum -like swing to 
the body. 

In the more advanced stages of locomotor ataxia the body is so far 
thrown forward that the patient can walk only by the help of two canes 
or crutches ; all the movements executed with the legs are performed with 
great stiffness and by sudden jerks. Still later in the disorder the wild, 
irregular, choreiform movements of the legs make walking impossible. 
Finally, if the lesion travels up the spinal cord, all power of coordinating 
the muscles of the trunk may be lost, so that the patient is no longer 
able to sit unsupported. 

Organs of Special Sense. — In the prodromic stage of locomotor 
ataxia transient ocular palsy with its resultant ocular diplopia not rarely 
occurs. In the later stages ptosis and internal or more rarely external 
squint are common symptoms ; and even a general ophthalmoplegia may 
occur. The pupil is usually pronouncedly myotic, but may be mydriatic, 
and often irregular. Argyll- Robertson pupil or reflex iridoplegia is almost 
characteristic of the disease, and may be a late or an early symptom. In 
it the pupillary reflexes are abolished, but the pupil reacts with accom- 
modation, so that although pinching of the skin of the neck or throwing 
light suddenly into or shutting light suddenly from the eye produces no 
pupillary movement, the pupil dilates when the gaze is suddenly directed 
from a near to a distant object. Contraction of the field of vision with 
disorder of the color sense is very frequent 5 the contraction is concen- 
tric, but usually somewhat irregular. Perception fails early for green 
and red, is long maintained for yellow and blue. These visual phenomena 
are caused by degeneration of the optic nerve. Deafness is infrequent ; 
it may occur either as an early transient or as a late permanent symp- I 
torn. According to Gowers, it is accompanied by a progressive limi- 
tation of the range of hearing analogous to the contraction of the visual 
field, the notes of the scale, beginning at the top, dropping out of the 
range of hearing one after the other, until all are alike inaudible. 

Trophic Changes. — The most important trophic changes in locomotor 
ataxia are the perforating ulcer, alterations of the bones and joints, and 
perhaps cardiac disease. The perforating ulcer may attack the hands or 
the internal organs, but usually affects the foot. As it occurs in other 
diseases than locomotor ataxia, it will be found described under trophic 
diseases. (See page 621. ) 

As was first stated by Yulpian in 1879, valvular disease frequently 
occurs in locomotor ataxia, especially showing itself in insufficiency of 
the aortic valve. It is uncertain how far the various valvular lesions 
are directly secondary and trophic, but when a sharply defined perfo- 
rating ulcer forms upon a valve in a case which suffers from a severe 
cardiac crisis, the existence of a trophic influence can scarcely be denied. 

Tabetic arthropathy may first manifest itself by a peculiar articular 
crepitus $ when fully developed the arthropathy consists of a serous 



DISEASES OF THE SPINAL COED. 



581 



effusion, free from blood, pus, or albuminous flocculi, in the articular 
cavity and extending it may be into the tissues outside of the joint, 
which is enormously swollen, hard, pale, and so resistant as not to yield 
to pressure. In the second stage of the affection the joint remains 
swollen, but is hard and bony, with an evident increase in the size of 
its bony surfaces. Destruction of the articulating surfaces marks the 
third stage ; the epiphyses especially undergo atrophy, and even the 
head of the bone may be to some extent absorbed, the ligaments are 
elongated, and at last a condition of subluxation or perhaps of com- 
plete luxation results. The ataxic arthropathy is usually more or less 
symmetrical ; it attacks especially the knees, but is frequent in the 
foot and in the hand. The atrophic shafts of the bones may undergo 
spontaneous fractures, and dropping out of the teeth, one by one or in 
mass, may result from wasting of the alveolar processes. The primary 
change in the bone is probably always an hypertrophy, the atrophy being 
secondary. 

Diagnosis. — Two stages of locomotor ataxia are recognized by some 
systematic writers, the first or pre-ataxic being that which precedes the 
development of pronounced ataxia, the second that of ataxia. This 
division of the disease is altogether arbitrary, although it has a measure 
of usefulness in calling attention to the fact that the ataxia is com- 
monly a late symptom ; it may, however, develop early in the dis- 
ease, or at least without the long presence of the ordinary symptoms 
of the first stage. In the majority of cases the symptom to which the 
patient's attention is earliest directed is pain, which is not rarely long 
treated under the supposition of its being rheumatism. Careful examina- 
tion will at this time generally show that the knee-jerks are either want- 
ing or greatly diminished, and usually some disorder of coordination 
can be discovered. The Argyll-Eobertson pupil belongs in its first de- 
velopment to the early stage of locomotor ataxia, as do the transitory 
attacks of ocular motor paralysis, diplopia, etc. Permanent irregulari- 
ties of the pupil, and contraction of the field of vision, usually come on 
towards the end of the first stage or later ; they may, however, develop 
very early. Persistent vertigo occurs most frequently in the advanced 
stages of the disease. 

The diagnosis of the advanced stage of locomotor ataxia is so easy as 
to require no further discussion, but the recognition of the disease in its 
incipiency may be very difficult. The bilateral character of the pains 
and the absence of soreness should always give rise to the suspicion that 
they are not of rheumatic origin. Nevertheless, gouty pains may have 
all the character of locomotor ataxia pains. If the pains be associated 
with Argyll-Eobertson pupil, or with loss of the knee-jerk, or with any 
disturbance of coordination, there is sufficient ground for the diagnosis 
of a probable locomotor ataxia. The occurrence of three of these symp- 
toms makes the diagnosis positive. 



582 



DISEASES OF THE NERVOUS SYSTEM. 



A pain crisis is of more diagnostic importance than lancinating pains. 
In rare cases, especially in cardiac crisis, there may be difficulty in dis- 
tinguishing between the tabetic crisis and a functional pain attack such 
as that of angina pectoris. The seat and character of the pain, however, 
very rarely, if ever, exactly accord with the manifestations of the dis- 
ease which is simulated. Thus, in a cardiac crisis the pain will centre 
in one shoulder or in an axilla, or will shoot into the abdomen, or into 
the right arm, etc. 

A very important distinctive mark of the crisis is the sudden re- 
sumption of normal activity in the organ so soon as the pain ceases : 
moreover, there is no sign of disease in the organ between the paroxysms. 
Thus, after a gastric crisis the patient at once will begin to take and 
digest food, whilst a man who has had a cardiac crisis will be able to 
go up-hill, to run up-stairs, etc., without difficulty. When, however, as 
especially occurs in cardiac crises, there are trophic or other organic 
changes in the organ, functional power may be permanently altered ; as 
in these cases the sclerosis may be so situated that the legs offer no ataxic 
symptoms, bulbar symptoms should be carefully looked for ; giddiness, 
Argyll-Eobertson pupil, diplopia, or strabismus would be almost decisive. 
The import of the ordinary visual symptoms of ataxia is so serious that 
whenever they occur in a middle-aged person and are neither hysterical 
nor gummous they should give rise to the suspicion of tabes, especially 
if there be any history of old syphilis. 

Prognosis. — The course of locomotor ataxia is in most cases ex- 
tremely slow. The pre- ataxic stage may last ten or even twenty years, 
and the whole course of the disease stretch over a quarter of a century. 
Eemissions of months or years without change for the worse are frequent ; 
but we do not believe that a case of posterior sclerosis sufficiently de- 
veloped to be positively recognized is ever cured. In women the disease 
does not prevent a successful pregnancy, which may for the time being- 
hold the symptoms in abeyance, but has no permanent effect upon them. 
Death usually takes place from some intercurrent disease, but may be 
the result of chronic periencephalitis, or even of a sudden acute peri- 
encephalitis. Subacute myelitis is also said sometimes to occur as a 
complication. 

Treatment. — In the management of locomotor ataxia rest, both 
bodily and mental, is vital. The life of the patient should be perma- 
nently arranged in such a way as to avoid all unnecessary expenditure 
of vital force. Physical labor is of course impossible, and mental work 
should be so reduced that it will merely be sufficient to divert the atten- 
tion of the patient from himself. Absolute rest in bed for a series of 
weeks, combined with the use of massage to prevent the bad effects upon 
the general health which such confinement tends to produce, is often of 
the greatest service, and may produce a remission of the symptoms which 
will last for months or even years. Under no circumstances should the 



DISEASES OF THE SPINAL CORD. 



583 



patient be allowed to take long walks ; the effects of a single over- fatigue 
may last for many months. 

Sexual intercourse should be as far as possible avoided. It is affirmed 
by good authority to be especially harmful in those cases in which there 
is a tendency to atrophy of the optic nerve, with increasing impairment 
of vision, rapid blindness having, under these circumstances, followed 
a newly -contracted marriage. Whilst open-air life is useful, the most 
scrupulous care should be exercised to avoid exposure to wet or cold, 
and, when possible, the winters should be passed in a warm, dry climate. 

The diet in locomotor ataxia should always be nutritious, but non- 
stimulating 5 the very moderate use of wine or tobacco is not harmful, 
but the slightest excess is deleterious. 

The effect of drugs upon posterior sclerosis is very slight ; anti- 
syphilitic treatment is of no value, the contrary statements abundant in 
literature being based upon wrong diagnoses. We have not seen good 
produced by silver nitrate. Gold chloride and barium chloride are 
probably harmless remedies when not given in too large dose. Phos- 
phorus has powers for evil rather than for good. Ergot has been largely 
used for the purpose of acting upon the blood-vessels, but relaxed blood- 
vessels have nothing to do with development of locomotor ataxia. The 
effect of ergot in producing a tabetic affection justifies its use by those 
who believe in the ancient Hippocratic fantasy of similia similibus curan- 
tur ; we have used it repeatedly in large and in small doses without the 
slightest good effect. The continuous use of corrosive sublimate (one- 
fiffcieth of a grain three times a day) sometimes does good. 

The chief value of drugs in the disease is for the purpose of giving 
relief of symptoms as they arise, and for the moral support that comes 
to many individuals from the feeling that something is being done for 
them. Antipyrin, antifebrin, and phenacetin are very valuable analge- 
sics, which have a distinct controlling influence over the nerve-storms of 
posterior sclerosis. They are much safer remedies than opium. Anti- 
pyrin may be given hypodermically, and in a severe crisis so administered 
in conjunction with morphine. In the use of morphine the practitioner 
must always remember the especial danger, in a chronic disease like loco- 
motor ataxia, of the formation of the opium habit. 

Counter-irritation is of no use, unless it be in the earliest formative 
stage of the disease. At such time the persistent use of the actual cautery 
along the spine may be justifiable. Later in the treatment it is to be ab- 
solutely condemned. In a crisis, sinapisms and other mild counter- irri- 
tation over the seat of the pain or over the root of the nerve supplying 
the affected part sometimes bring a measure of relief. It is essential to 
avoid using blisters or other counter-irritation which shall produce de- 
structive inflammation of the skin, as such inflammation is apt to become 
uncontrollable. Any blisters or sores upon the feet in locomotor ataxia 
should receive the most careful attention, as a perforating ulcer is said to 



584 



DISEASES OF THE NERVOUS SYSTEM. 



have followed so small an operation as the cutting of a corn. Very often 
in a crisis the application of moist heat in the form of the warm bath, 
hot fomentations, or even the hot- water bag, will give more relief than 
counter - irritation. 

Various natural springs have been much used in locomotor ataxia. 
In France, Aix-la-Chapelle is highly recommended ; in Germany, the 
carbonic acid thermal salt springs at Eehme and at Nauheim are most 
popular ; in the United States the Arkansas Hot Springs are greatly 
resorted to. The baths at Toplitz, Wildbad, and Eagatz, formerly in 
high favor, have, according to Striimpell, at present lost their reputa- 
tion. The whole question of which spring to select is probably decided 
according to the fashion of the hour rather than because one spring is 
really more valuable than the other. Whatever good is achieved is the 
result of the stimulating influence of hope, of travel, of freedom from 
care, of rest, aided by the hydrotherapeutic measures employed. Enor- 
mous amounts of mercury are habitually used at the Arkansas Hot 
Springs, and in cases in which gummous disease of the cord has been 
diagnosed as locomotor ataxia brilliant and unexpected results are some- 
times obtained. The vapor bath and very hot baths used for the purpose 
of producing excessive sweating often do harm in locomotor ataxia ; the 
continuous use of very cold baths or of cold packs also frequently acts 
unfavorably. The use of tepid baths with gentle friction, and of wet 
tepid compresses upon the abdomen or the legs, especially at night, is 
grateful and gives relief. The temperature of the water should be be- 
tween 80° and 90° F. The bath may be employed from once to three 
times a day, according to the strength of the patient. 

It is frequently asserted that electricity is a valuable remedy in the 
treatment of locomotor ataxia, but there seems no sufficient ground for 
believing that the assertion is correct. The galvanic current is usually 
selected and applied along the spinal cord ; some authorities are urgent 
that the current should be passed down the cord, others are equally posi- 
tive that the direction should be upward. There is no good reason for 
believing that the electrical current in these cases succeeds in getting 
through the thick, soft and bony tissues overlying the spinal cord. 
There is also no good reason for supposing that it is possible to stimu- 
late by the ordinary medical galvanic current the deeply situated sym- 
pathetic ganglia in the neck : further, it is hardly conceivable that stim- 
ulation of these ganglia could do any good in locomotor ataxia. In 
some cases of locomotor ataxia relief of pain has been obtained by the 
passage of galvanic currents along the nerve-trunks ; but it is probable 
that in these cases the central lesion was reinforced by a peripheral 
neuritis, and that it was the peripheral neuritis and not the centric 
lesion that was benefited. The local application of a dry brush with a 
' moderately strong current sometimes relieves the numbness of tabes. 

In all cases of tabes it is essential that the bladder be thoroughly 



DISEASES OF THE SPINAL CORD. 



585 



emptied at regular intervals. Even in the earlier stages micturition may 
be so imperfect that there is a residual urine, which undergoes fermen- 
tation and sets up a cystitis, which, although slight, may yet be sufficient 
gradually to involve the ureters and the mucous membranes of the pelves 
of the kidneys, and finally the kidneys themselves. In this is probably 
found the cause of frequent death from kidney disease in locomotor ataxia. 
No hesitation should be felt, in any case, in using the soft catheter, and 
when the urine is ammoniacal the bladder should be washed out thor- 
oughly every other day with a dilute solution of some acid antiseptic. 

Langenbach some years ago proposed for the cure of tabes the stretch- 
ing of the sciatic or other large nerve taking its origin in the affected 
region. The procedure is apparently devoid of any scientific basis, 
has been followed by death, and is not justifiable. The exploitation by 
Charcot of the method of Motschoutkowski — i.e., that of suspension — led 
to its universal adoption in the treatment of tabes. The claims made by 
Charcot have, however, not been confirmed, although in a number of 
cases there has been an apparent advantage. It is stated that lost sexual 
function is often restored. Motschoutkowski believes that there is an 
absolute stretching of the vertebral interspaces and a direct influence 
upon the cord, but at present there does not seem to be any physiological 
explanation of any good result which may be obtained by the procedure. 
Charcot teaches that oedema, obesity, phthisis, valvular or other cardiac 
lesions, emphysema, and marked atheroma of the arteries are contra- 
indications to the use of suspension, and certainly when either of these 
exists the practitioner is not justified in experimenting with the method. 
The best apparatus is probably that which is known in America as the 
Weir Mitchell apparatus. The suspension may be from five to fifteen 
minutes once a day, the spring balance always being used, that the 
amount of force applied to the head may be known. The physician him- 
self should always be present at the first suspension, and at subsequent 
seances at least a thoroughly trained reliable nurse should superintend. 

ANTERO-LATERAL SCLEROSIS. SPASTIC PARAPLEGIA. 

Definition. — A disease due to sclerosis of the antero-lateral columns 
of the spinal cord, characterized by spastic contractions, with partial 
loss of power and exaggerated reflexes, without sensory disturbances or 
trophic changes. 

Etiology. —The causes of antero-lateral sclerosis are those which 
produce posterior sclerosis. Our knowledge does not suffice to explain 
why in one case the sclerotic disease attacks one region, and in another 
case another region, of the cord. 

Morbid Anatomy.— The sclerosis may affect the whole of the lateral 
columns, but is usually developed in the so-called crossed pyramidal 
tract. Its history and microscopic anatomy are those of other scleroses 
in various positions of the cord. (See Locomotor Ataxia.) 



586 



DISEASES OF THE NERVOUS SYSTEM. 



Symptomatology. — Anterolateral sclerosis may develop at any age, 
but is a disease especially frequent in adult middle life, and, as the lesion 
is usually located in the lower segments of the spinal cord, commonly 
first shows itself by clonic or tonic spasm in the legs after prolonged 
exertion. A little later the loss of endurance during walking is mani- 
fested, and by and by the characteristic gait develops. The rigidity of 
the various muscles prevents the free bending of the knee- and hip -joints, 
whilst the heel is drawn up by the great power of the contractures of the 
calf- muscles. Unable to lift the toes from the ground, the subject raises 
and rotates the pelvis, so that the body is inclined during the step towards 
the leg upon which its weight is rested, whilst the toes are pushed for- 
ward with the greatest difficulty along the ground through a step of from 
three to six inches. In bad cases violent tremors are apt to occur in the 
legs during effort, and at such times rhythmical movements may throw the 
heels of the patient up and down in regular vibrations. As the disease 
progresses, the heels are drawn up permanently, so that the subject must 
stand upon the toes, thereby throwing the trunk forward and necessi- 
tating the use of crutches or canes held well in advance of the body. A 
little later than this, walking becomes impossible ; the leg is now usually 
flexed upon the thigh, the heel drawn up and the toes turned inward, — 
this position being due to the superior power of the posterior muscles of 
the thigh and leg and of the abductors as compared with their antagonists. 
In some cases the legs are stiffly extended, very rigid, with the feet in- 
verted and often crossed. Not rarely violent clonic spasms occur, from 
time to time causing rapid to-and-fro vibrations of the legs ; such spasms 
are especially frequent at night, are usually but not always painless, 
and constitute the condition which has been inappropriately named by 
Brown-Sequard u spinal epilepsy. 77 

There are no pronounced sensory or trophic symptoms, or at most 
there is slight numbness or paresthesia. For reasons which are not ap- 
parent, lateral sclerosis is rarely followed by peripheral nerve changes, 
so that ocular and laryngeal and other peripheral symptoms are un- 
common. The mind is rarely affected, unless the sclerosis exists as a 
secondary complication of a general paralysis. From the beginning the 
deep and superficial reflexes are exaggerated, the slightest touch pro- 
ducing a quick and violent response. Ankle-clonus and knee-clonus 
are common phenomena. Sometimes the touch of the bed or of the 
floor suffices to throw the muscles of the legs into violent clonic con- 
tractions. In advanced cases the contractures may be so great that the 
reflexes are entirely abolished. 

Diagnosis. — The diagnosis of lateral sclerosis rests upon the gradual 
development of loss of power which is accompanied by contractures and 
heightened reflexes and so situated as to be evidently of spinal origin, 
combined with the absence of girdle sensation, of pain, and of disturb- 
ance of sensation, of paralysis of bladder or rectum, of trophic changes, 



DISEASES OF THE SPINAL CORD. 



587 



and of disorder of coordination. The diseases which produce groups 
of symptoms more or less closely simulating lateral sclerosis are spinal 
meningitis, chronic cerebral disease with secondary degeneration, and 
hysteria. 

Spinal meningitis is accompanied by excessive pain, and any attempt 
at the extension of the affected limbs produces suffering which is much 
greater than that caused by similar procedures in lateral sclerosis. 

The lesions of lateral sclerosis are practically the same as those of 
descending degeneration from cerebral diseases, and the symptoms are 
very similar, except in their distribution. Cerebral lesions are usually 
unilateral, spinal lesions bilateral. Almost invariably, therefore, a henii- 
plegic or a monoplegic character will betray the secondary degeneration. 
In rare cases a spinal sclerosis may in its early stages affect one side 
of the cord more than the other, but it is probably never purely 
hemiplegic. The two affections have also different histories : spinal 
spastic paralysis always develops slowly and insidiously, cerebral spas- 
tic paralysis dates back to birth or to an acute attack with cerebral 
symptoms. 

The real difficulty of diagnosis is between hysterical and spinal spas- 
tic paralysis, a difficulty which is enhanced by the fact that hysterical 
contractures may in time be converted into antero-lateral sclerosis. In a 
case reported by Charcot contractures of all four extremities developed 
suddenly in a woman and continued for ten years, with temporary inter- 
missions ; after the last seizure the contractures continued until death, and 
at the autopsy symmetrical lateral sclerosis was found to extend almost 
the entire length of the cord. The rule laid down by Charcot is that 
whenever marked atrophy of the muscles and persistence of the contrac- 
tures during anaesthesia are present organic degeneration of the spinal 
cord has set in. We have certainly seen the distinct hysterical contrac- 
ture gradually take on the absolute clinical picture of an old lateral 
sclerosis. Ankle- clonus is not peculiar to either spinal or hysterical 
spastic paralysis ; it occurs in each. It is probable that the peculiar 
lead-pipe rigidity seen at a certain early stage of spastic paralysis never 
occurs in hysteria. The great difficulty is the separation of the severe 
types of the two diseases. The distinguishing points in the hysterical 
disorder are the suddenness of its development, the history of marked 
hysterical symptoms in the past, the presence of anaesthesia or of other 
hysterical symptoms, and the occasional sudden intermission of con- 
tractures. Contrary to the statements of Charcot, our own experience 
shows that the hysterical contracture does not always relax during 
etherization. 

Prognosis.— The history of lateral sclerosis is that of other forms of 
sclerosis, except that secondary complications are much less apt to occur 
than in locomotor ataxia, and consequently life is more prolonged and 
is free from suffering. 



588 



DISEASES OF THE NERVOUS SYSTEM. 



Treatment. — Absolute rest in bed is sometimes of great temporary 
benefit in lateral sclerosis. Drugs have no effect upon the sclerotic 
tissue ; nerve-stretching and suspension have probably about the same 
value as in posterior sclerosis. 

COMBINED SCLEROSES. 

Spinal scleroses of vertical tracts may coexist in various combina- 
tions, producing cases which clinically present various mixtures of 
symptoms according as the disease is more pronounced in one or other 
of the spinal tracts. These mixed cases have in general an etiology, 
pathology, prognosis, and treatment similar to those of the affections 
in which the lesion is not so wide- spread. 

Although the mixed cases vary so much in rare instances as to baffle 
a simple description, two types of cases are so discernible that they have 
been described as distinct diseases. 

The first of these types is the so-called Ataxic Paraplegia, in which 
there is a mixture of posterior and lateral sclerosis. Like other forms of 
sclerosis, this disease develops very insidiously. According as the lesion 
affects chiefly one column or the other the symptoms of the locomotor 
ataxia predominate or the lights and shadows of the clinical picture are 
chiefly those of the lateral sclerosis. Usually the tendency of the re- 
flexes to be lost, so strongly pronounced in locomotor ataxia, is overcome 
by the irritation of the lateral columns, with the result of a loss of power 
of endurance, with loss of coordination and preservation or even excita- 
tion of the reflexes. The sensory symptoms are commonly not so severe 
as in tabes ; fulgurant pains are uncommon ; the girdle sensation is not 
present in a majority of cases. Ocular disturbance may or may not exist. 
The gait is a curious mixture of that of spastic paralysis with that of 
posterior sclerosis. 

In some cases of ataxic paraplegia the disease begins in one tract 
alone, when may be seen the curious picture of a locomotor ataxia having 
the reflexes return and in other ways gradually conforming to a lateral 
sclerosis type ; or the reverse of this may happen. 

In Amyotrophic Lateral Sclerosis, so called, there is poliomyelitis ac- 
companied by a pronounced sclerosis of the pyramidal tracts. It is very 
rare indeed in an old case of poliomyelitis not to find some sclerotic 
change in the motor tract, and there is also a regular series of cases 
grading between those in which poliomyelitis is supreme and those in 
which the lateral sclerosis is dominant. There does not seem to be at 
present sufficient reason for believing that either of these lesions is neces- 
sarily secondary to the other ; they may each have their beginning in the 
original myelitic attack. 

The symptoms of amyotrophic lateral sclerosis are wasting of the 
muscles, with loss of power, spastic contractions, and heightened re- 
flexes. The upper extremities are usually first attacked ; sometimes a 



DISEASES OF THE SPINAL CORD. 



589 



hemiplegia arrangement of the symptoms is seen, and very frequently 
the trophic changes predominate in the arms, the spastic symptoms in 
the legs. The cranial nerves are usually affected very early, and there is 
an amyotrophic lateral sclerosis of the medulla which causes glosso-labial 
paralysis with spastic symptoms ; when the sclerosis is not very pro- 
nounced the only evidence of its existence distinguishing the case from 
one of simple bulbar paralysis may be an increase of the jaw reflexes. 

There can be no difficulty in recognizing the nature of a typical case 
of amyotrophic lateral sclerosis ; but if the motor cells degenerate very 
rapidly the loss of muscle-tone may be sufficient to mask more or less 
completely the sclerosis of the white matter. Under these circum- 
stances a slight stiffness of gait (the u frozen attitude") may alone reveal 
the true nature of the case. 

The prognosis in amyotrophic lateral sclerosis is very unfavorable, 
death almost invariably resulting in from one to five years. No medi- 
cinal treatment is of any avail, but long- continued rest in bed, with 
massage, and careful nursing, may be serviceable. 

FRIEDREICH'S ATAXIA. 

Definition. — A family disease, characterized by ataxic symptoms, 
nystagmus, contractures, and wide-spread paresis with subordinate dis- 
orders of sensation. 

Etiology. — Friedreich's ataxia, although it almost invariably occurs 
in a number of individuals in the same family, is rarely directly in- 
herited from parents, but is an outgrowth from an original neuropathic 
stock whose tendency to degeneration is further increased by intemper- 
ance, tuberculosis, or syphilis in the parent, and by consanguineous mar- 
riages. The attack frequently develops without immediate cause, but 
in some instances has been precipitated by an attack of typhoid fever, 
scarlatina, diphtheria, or other acute disorder. 

Morbid Anatomy. — In almost all the autopsies in cases of heredi- 
tary ataxia there has been found a sclerosis of the lateral or crossed cere- 
bral tract and of the posterior columns of the spinal cord, and usually 
also one of the direct cerebral tract and of the cerebellar tract. The 
column of Clarke is also usually more or less degenerated. Nonne has 
reported one case in which there was no spinal sclerosis, but in which 
the cerebrum, cerebellum, pons, medulla, and cord were remarkably small, 
a condition which has also been noted in various cases in which sclerotic 
changes were pronounced. It is not probable that any of the scleroses is 
peculiarly primary. They are all probably the result of a common in- 
fluence ; it is possible that they are merely accidental complications of or 
developments from an original lesion. The nature of the fundamental 
lesion of the disease remains in doubt, the most probable theory being 
that of Kahler and Pick, in accordance with which the foundation of the 
disease is the imperfect development of the nerve-fibres. There is also 



590 



DISEASES OF THE NERVOUS SYSTEM. 



an appearance of trnth in the further generalization of Pick, that this 
failure of development is due to early vascular degeneration. Eecent 
observers, however, deny that there is any alteration of the vessels, 
stating that in this fact Friedreich's ataxia absolutely differs from true 
locomotor ataxia. 

Sclerosis of the posterior nerve-roots has been frequently noted, and 
Auscher states that the peripheral nerves are not found in a condition of 
degeneration, but have many of their nerve-filaments preserving their 
embryonal condition, — i.e., being simply nerve-tubes without myelin. 

Symptomatology. — Sixty per cent, of the cases of Friedreich's ataxia 
have developed insidiously before the tenth year of age, but in individual 
cases various evidences of prolonged irregular nervous disturbances have 
been present. Usually the first symptom is a peculiar awkwardness, in 
most cases beginning in the legs, but sometimes attacking the speech, 
the lower extremities, and the upper extremities simultaneously, and 
very rarely taking a monoplegic and even a hemiplegic form. 

The most characteristic symptom is the incoordination, which may 
produce a gait exactly resembling that of tabes, or may reveal itself in a 
peculiar step in which there is a strong tendency to the lateral projection 
of the foot, or in a rolling walk like that of alcoholic intoxication. In 
the arms the loss of coordination is evinced by irregular jerking move- 
ments and by the inability to perform delicate acts, and often becomes 
so extreme that in the impossibility of properly apposing the fingers the 
action of the hand resembles that of a paw. The ataxia of quiet action 
which Friedreich affirms to be characteristic of the disease and never to 
be present in locomotor ataxia is usually a rather late symptom, and is 
shown in the inability of the subject to hold the extremity in any quiet 
somewhat forced position. This static ataxia may be so severe as to pro- 
duce peculiar athetoid symptoms in the fingers when lying in the lap, or 
a wavy or non-rhythmic oscillation in the arms and legs when at rest, or 
tremors, oscillations, or choreiform movements in the head. In rare cases 
these movements occur only under excitement, and simulate an intention 
tremor. 

In all the cases recorded by Friedreich the knee-jerk was early abol- 
ished. It may, however, be normal or even exaggerated ; an ankle- clonus 
has been noted. The attempt to make varieties of the disease based 
upon the condition of the knee-jerk is futile, since the condition of 
the knee-jerk must depend upon the position or development of the 
spinal sclerosis, which is probably only a secondary lesion. 

Incontinence of urine is a very rare symptom, and sexual power is 
usually long preserved. Muscular weakness is sometimes spoken of as 
an initial symptom, and in the advanced disease may amount to an almost 
complete wide- spread paralysis. In a few cases the muscles undergo 
atrophy, which is rarely attended with the reaction of degeneration. 
Contractures are very frequent in the later stages of the disease, and not 



DISEASES OF THE SPINAL CORD. 



591 



rarely give rise to deformities, such as curvature of the spine (which has 
been noted in about one- third of the cases reported), talipes equinus, 
and other forms of club-foot, besides various distortions of the limbs, toes, 
and fingers. Fulgurant pains may be an early symptom of the affection, 
but are usually absent throughout, the only disturbances of sensation 
consisting of aching pains, slight numbness, and various paresthesias, 
which are rarely severe ; the girdle sensation has been noted in only a 
small proportion of the cases. 

Disorder of speech is usually a late symptom. It varies in form and 
intensity : sometimes the subject speaks with hesitation and a drawl, 
sometimes the words are thrown out in a jerky, almost stuttering manner, 
whilst typical scanning has been reported. Irregularity of pitch, indis- 
tinctness of utterance, slurring of the syllables, in various cases have in- 
dicated that the laryngeal muscles are affected. Evident lack of control 
in the movements of the tongue and lips, tremors, choreic or oscillating 
movements of the tongue, fibrillary contractions of all the muscles about 
the mouth, loss of power of holding the saliva in the mouth, with a loss 
of tone in the muscles of expression, — any or all of these symptoms may 
be present as the outcome of a deep-seated bulbar involvement. 

The eye- symptoms are peculiar. Strabismus with diplopia sometimes 
occurs ; blepharospasm with ptosis has been occasionally noted ; but the 
characteristic though usually late manifestation of the disease is nystagmus. 
This may take the form of what Friedreich calls ataxic nystagmus, — 
namely, oscillating movements appearing when the eyes are- turned upon 
some object held near; or that of static nystagmus, — that is, movements 
when the eyes are supposed to be at rest. The pupillary movements may 
be sluggish, but they are always present, and the Argyll-Eobertson pupil 
has never been noticed. Atrophy of the optic nerve is rare. Vision is 
occasionally impaired, but contraction of the field has been observed only 
a few times. Color sense seems not to have been studied. 

Although coldness and blueness of the extremities are ordinary vaso- 
motor phenomena of the disease, no trophic changes of the joints and 
bones have been reported. The intellect is often dull, but there is never 
acute mental aberration. 

Diagnosis. — The symptoms of Friedreich's ataxia vary greatly ac- 
cording to the situation and the development of the spinal sclerotic 
changes. Usually the nature of the case can be recognized by the occur- 
rence of several cases in one family, the subordination of the sensory to 
the motor symptoms, and the static incoordination, with the subsequent 
oscillating or choreic movements and the presence of disturbance of 
speech, and of nystagmus. 

Prognosis and Treatment.— Friedreich's ataxia is incurable, but 
has little tendency to produce death, which almost invariably occurs 
from some intercurrent disease, it may be, as long as forty years after 
the first symptoms. Treatment is of no avail. 



592 



DISEASES OE THE NERVOUS SYSTEM. 



SPINAL SYPHILIS. 

Syphilis may produce disease of the blood-vessels of the spinal cord 
and its membranes, with consequent hemorrhage, softening, etc., or it 
may give rise to a gummous infiltration which commences in the pia 
mater and spreads inward, causing thickening of the blood-vessel walls, 
with dilatation of the perivascular spaces and exudation of minute cells 
around the vessels. The so-called syphilitic callus, a condensation of 
the fibrous tissues around the cord, is probably not a primary syphi- 
litic lesion, but the scar or remnants of a true gummous infiltration of 
the membranes. 

Symptomatology. — Spinal softening and spinal neoplasms due to 
syphilis produce symptoms similar to those caused by similar lesions 
not due to syphilis. The symptoms of gummous spinal meningitis are 
those of a localized subacute meningitis, — namely, pain and spasm, with 
paralysis, affecting some peripheral part corresponding to the seat of the 
lesion. The pains are sometimes exceedingly severe, furious agonies 
shooting along the affected nerves or fulgurant crises simulating those of 
true locomotor ataxia. Often there is aching in the back. When this 
aching is accompanied by marked soreness on pressure or on jarring, the 
vertebrae themselves may be considered to be affected. Various paraes- 
thesise, marked hyperesthesia or anaesthesia, girdle pains, tonic spasms, 
localized tremors, grossly exaggerated reflexes, — such are the symptoms 
of irritation, which may be followed by complete paralysis with trophic 
changes. 

The symptoms of diffused syphilitic infiltration of the cord vary with 
the seat of the lesion, simulating now locomotor ataxia, now spastic para- 
plegia, now chronic myelitis. 

Diagnosis. — The diagnosis of spinal syphilis is usually to be reached 
by a study of the collocation of the symptoms rather than of the symp- 
toms themselves. 

The lesions of syphilis are prone to be multiple, and are rarely as 
strictly confined to individual functional tracts as in sclerosis : conse- 
quently, the symptoms of syphilis of the cord are very apt to be mixed. 
Thus, there will be loss of coordination associated with retention of the 
patellar reflex ; or the patellar reflex may be lost at a time when there is 
marked loss of power in the muscles rather than loss of their coordinating 
function ; or an apparent locomotor ataxia will be associated with loss of 
power over the rectum or the bladder ; or a case which up to a certain 
point offers a typical outline of lateral sclerosis suffers from fulgurant 
pains or from paralysis of the sphincters. 

Almost any conceivable mixture or interweaving of spinal symptoms 
may occur as the result of syphilis of the cord, so that the most pathog- 
nomonic evidence of the existence of the disease is an atypical aggre- 
gation of symptoms. Whenever the practitioner is confronted by a 



DISEASES OF THE SPINAL CORD. 



593 



contradictory mass of phenomena evidently spinal in origin, suspicion 
should be strongly aroused. 

Prognosis and Treatment. — Spinal syphilis is often very favorably 
affected by treatment, but in a majority of the cases it leaves behind it 
some permanent traces. Owing to the narrow boundaries of the cord, 
the secondary pressure and inflammatory effects of specific deposits are 
most serious : hence the treatment of a case of spinal syphilis should be 
very vigorous, mercury being used with the utmost freedom, unless there 
be pronounced cachexia, for the purpose of producing as rapid change as 
possible. After the mercurial course enormous doses of the iodide should 
be given, preferably in milk. 



38 



594 



DISEASES OF THE NERVOUS SYSTEM. 



CHAPTEE VI. 

ORGANIC DISEASES OF THE NEE, YES, 

As affording to the student a convenient method of study, and, to the 
medical practitioner, of reference, we shall begin the present chapter by 
pointing ont the exact seat of the palsies which follow loss of function 
in the more important individual nerves. In the distribution of paraly- 
sis it makes no difference, of course, whether the lesion is centric or 
peripheral. Having, however, located the nerve territory of a paraly- 
sis, the practitioner should usually have no difficulty in deciding by 
an electrical study of the affected muscle whether the lesion is cen- 
tric or peripheral, — it being understood that the word peripheral as 
here used includes the trophic centres in the spinal cord as well as 
the motor nerves. Localized spasms are, of course, referable to their 
proper nerve by reading spasm instead of paralysis in the text. 

LOCAL PARALYSES OF MOTION. 

Oculo- Motor Paralysis. — Dilatation of the pupil, ptosis or dropping 
of the upper lid, paralysis of accommodation, and squint with consequent 
double vision, are symptoms of loss of power of the oculo-motor nerve, 
whose superficial origin is from the inner border of the crus cerebri, the 
deep origin being in the locus niger of the peduncles and the gray nucleus 
in the floor of the aqueduct of Sylvius slightly below the tubercula quad- 
rigemina. Partial paralysis of this nerve is frequent. In such cases 
the symptoms vary according to the portion of the nerve affected. The 
functions of the eye-muscles are as follows : to turn the eye— superior 
oblique, downward and outward ; inferior oblique, upward and outward ; 
superior rectus, upward and inward ; inferior rectus, downward and 
inward ; internal rectus, directly inward ; external rectus, directly out- 
ward. All these muscles are supplied by the oculo-motor nerve except 
the superior oblique and the external rectus. When one of these muscles 
is paralyzed a squint results. In order to determine which muscle is 
affected, it is only necessary, at least in cases of fresh paralysis, to note 
the position of the head. The rule is, the head is so deflected that the 
chin is carried in a direction corresponding to the action of the paralyzed 
muscle. Megalopsia, or macropsia, in which objects look larger than 
normal, is said to indicate paralysis of the external rectus. Micropsia, 
in which objects look smaller than normal, is said to indicate paresis 
of the internal rectus. These two symptoms are very rare. 

Paralysis of the oculo-motor nerve, also of the trochlear and of the 
abducens, is commonly due to pressure upon the nerve by basal exuda- 
tions, which in adults are usually syphilitic, in children tubercular or 



ORGANIC DISEASES OF THE NERVES. 



595 



rachitic. Bheumatic or gouty paralysis is not very rare. Centric palsy 
may occur. 

Fourth or Trochlear Nerve. — Loss of power of the superior oblique 
muscle of the eye is diagnosed by the fixedness of the eye when the head 
is moved, or, in other words, by the moving of the eye with the head. 
Double vision occurs whenever the subject attempts to look straight 
downward or at objects situated towards the paralyzed side ; but the 
second image disappears when the head is turned to look towards the 
sound side. The distortion of vision is especially manifested when any 
attempt is made to pick up a small object, as a coin, off a table. The 
nerve involved is the fourth, trochlear, or pathetic, whose apparent or 
superficial origin is in the superior peduncle of the cerebellum. Its 
fibres have been traced into the peduncle to the valve of Yieussens, 
near the tubercula quadrigemina, where they decussate with correspond- 
ing filaments of the opposite side. 

Ophthalmoplegia. — Under the name of ophthalmoplegia interna Jona- 
than Hutchinson described an affection of the eye which he believed to 
be the result of paralysis of the ciliary ganglion. The symptoms are 
iridoplegia, or paralysis of the iris, both as to the circular and the 
radiating fibres, and cycloplegia, or paralysis of the ciliary muscle. 

Ophthalmoplegia externa of Hutchinson, previously described by Yon 
Graefe as ophthalmoplegia progressiva, is paresis or paralysis of all the 
external muscles of the two eyes. In most cases the internal muscles 
are affected. The cause may be an exudation beneath the brain in- 
volving both sets of nerves, or a poliomyelitis attacking the nuclei of 
the nerves. 

Fifth or Trigeminus Nerve.— Loss of power in the muscles of mas- 
tication, — i.e. j the temporal, masseter, and pterygoids, — and in the mylo- 
hyoid, digastric, tensor palati, and tensor tympani, indicates paralysis 
of the motor root of the fifth or trigeminus nerve. This root has its ap- 
parent origin in the side of the pons j its deep origin is in a nucleus just 
below the lateral angle of the fourth ventricle, immediately in front of 
the nucleus of the facial nerve. 

Paralysis of those fibres of the trigeminal or fifth nerve which come 
from the ascending or sensory root produce loss of sensation in the face, 
including the forehead, the eye, and the external ear, and also in the 
mucous membrane of the mouth, the hard and the soft palate, the nose, 
and the middle ear, and in the teeth. Disturbances of the trigeminal 
nerve are also apt to be accompanied by disorder of the secretory func- 
tion of the lachrymal, nasal, and buccal glands, by herpetic eruption, 
and by a severe conjunctivitis which is believed by some to be of tro- 
phic origin, and by others to be caused by the loss of sensibility pre- 
venting the immediate recognition of foreign bodies in the eye. 

Sixth or Abducens Nerve. — Paralysis of the abducens nerve causes 
loss of power in the external rectus, with consequent internal strabismus, 



596 



DISEASES OF THE NERVOUS SYSTEM. 



or squint, double vision, and sometimes macropsia. Internal squint does 
not, however, always indicate paralysis of the sixth nerve, because the 
weakness of the external rectus muscle is a very frequent result of im- 
perfection of vision. The apparent origin of the abducens nerve is from 
a groove between the anterior pyramid of the medulla and the posterior 
border of the pons. There are usually two roots, one from the medulla 
and the other from the pons. The fibres have been traced to a nucleus 
which lies underneath the fasciculus teres in the floor of the fourth ven- 
tricle. A few fibres are believed to pass from this nucleus upward and 
across to join the third nerve of the opposite side. In this way are ex- 
plained certain rare cases of conjugate paralysis involving the internal 
rectus of one side and the external rectus of the other side and accom- 
panied by atrophy of the nucleus of the abducens nerve. 

Facial Nerve. — Of all the nerves of the body the facial or seventh 
nerve is most frequently paralyzed. The superficial origin of this nerve 
is in a groove between the olivary and restiform bodies of the medulla. 
Its deep origin is probably in the upper portion of the pons, although its 
fibres have not been distinctly traced farther than a nucleus in the upper 
half of the floor of the fourth ventricle near the postero-median fissure. 
It supplies all the muscles of the face, except those of mastication, also 
the levator palati and the tensor tympani. 

Centric paralysis of the facial nerve is common. It is never complete, 
and almost invariably affects the muscles about the corner of the mouth. 
Complete paralysis of the nerve is always peripheral, and is usually due 
to neuritis or perineuritis. For an account of it, and also of paralysis of 
different portions of the nerve, see Neuritis, Facial, page 611. 

Auditory Nerve. — The eighth, or auditory, nerve has the nucleus of 
its larger root in the floor of the fourth ventricle, that of its minor root 
near the restiform body. The roots pass obliquely outward and unite 
into a single trunk, which appears at the lower edge of the pons on the 
outer side of, and close to, the facial nerve. After leaving the medulla 
oblongata the nerve is directed outward, in company with the facial 
nerve, to the internal auditory meatus. 

Deafness from disease of the auditory nuclei is very rare. Peripheral 
neurotic deafness is much more common. The auditory nerve is liable 
to be pressed upon by syphilitic, tubercular, or other deposits at the 
base of the brain, and is especially exposed to paralysis from disease of 
the mastoid processes of the temporal bone. It may therefore be laid 
down as a diagnostic rule, the exceptions to which are very rare, that 
a nervous deafness not associated with marked giddiness is dependent 
upon a lesion of the nerve-trunk. Hyperesthesia of the auditory nerve 
produces a loss of hearing which is characterized by excessive suscepti- 
bility to sounds. The normal stimuli of the nerve produce pain rather 
than normal functional excitement, so that, although unable to perceive 
minute differences in sounds, the patient suffers acutely from loud noises. 



ORGANIC DISEASES OF THE NERVES. 



597 



PNEUMOGASTRIC NERVE. 

The important branches of this nerve are the pharyngeal, the laryn- 
geal, and the cardiac. 

Pharyngeal Branches. — As these branches in connection with the 
glossopharyngeal nerve form the pharyngeal plexus, their paralysis is fol- 
lowed by difficulty of swallowing. The part played in the formation of the 
plexus seems, however, somewhat secondary, as loss of power in a single 
pneumogastric nerve does not seriously impair the power of swallowing. 

Laryngeal Branches. — The superior laryngeal nerve supplies the 
laryngeal membrane above the cords and the crico-thyroid muscle ; the 
inferior or recurrent laryngeal supplies the remainder of the mucous 
membranes and muscles of the larynx. Owing to its proximity to the 
arch of the aorta on the left and the subclavian artery on the right side, 
the inferior nerve is frequently involved in aneurisms. 

The symptoms of paralysis of the laryngeal muscles vary according 
as the abductors or the adductors are affected. Adductor paralysis is the 
common form, producing the hoarseness or aphonia of hysteria, ordinary 
colds, etc., without disturbances of respiration. The muscles involved 
are the lateral crico-arytenoid and the arytenoid. 

The failure of the abductors, the posterior crico-arytenoids, to draw 
apart the vocal cords during inspiration, results in the glottis being 
almost or entirely closed by the pressure of the air from without, so that 
inspiration is almost impossible and is accompanied with a loud stridor. 
This form of laryngeal paralysis is dangerous to life. It may result from 
pressure upon both vagi or both recurrent nerves, but may be due to a 
central lesion or to hysteria. When only one nerve is involved there is 
merely hoarseness with failure of the cord to move in inspiration, as seen 
by the laryngoscope. Spasm of the abductor muscles seems to be rare, 
and to produce only disturbances of voice ; on the other hand, spasm 
of the adductors by closing the glottis causes violent dyspnoea, as in 
laryngismus stridulus, false croup, etc. 

Anesthesia of the larynx is especially important, because by pre- 
venting the automatic watchfulness of the glottis it is apt to lead to 
the entrance of particles of food into the larynx or the lungs. It is a 
common condition in advanced dementia paralytica. 

Cardiac Branches. — So far as concerns the heart, the vagi have 
motor, sensory, and trophic functions ; irritation of the vagi produces 
slowness, paralysis of the vagi great rapidity, of the heart's action. 
We do not know what symptoms are produced by disturbances of the 
sensory fibre of the pneumogastric ; it may be that the pain of angina 
or other heart disease is connected with them. 

Pulmonary Branches. — Of these we have not sufficient knowledge 
to speak with any confidence. It is possible, but not proved, that 
asthma is connected with them. 



598 



DISEASES OF THE NERVOUS SYSTEM. 



Gastric and Oesophageal Branches. — These branches play an im- 
portant part in the act of vomiting. They probably carry both afferent 
and efferent impulses between the base of the brain and the stomach. 
Gastralgia, or neuralgia of the stomach, is believed by some authorities to 
be an irritation of the pneumogastric peripheral endings, and it is pos- 
sible that these nerve terminations are connected with many dyspeptic 
disturbances. 

Glosso-Pharyngeal Nerve.— Paralysis of the glossopharyngeal 
nerve is revealed by difficulty of swallowing, with great tendency to 
regurgitation of food through the nostrils, and loss of taste in the pos- 
terior third of the tongue. The superficial origin of the nerve is in the 
groove between the lateral tract and the restiform body of the medulla 
oblongata. Its fibres have been traced to a nucleus in the floor of the 
fourth ventricle. 

Spinal Accessory Nerve. — The spinal accessory nerve is composed 
of fibres springing from the lateral columns of the medulla oblongata and 
of fibres which rise between the anterior and posterior roots of the first 
and fifth cervical nerves, the two parts being united in the cranium and 
escaping as one nerve through the jugular foramen. The spinal accessory 
nerve sends communicating fibres to the pneumogastric, which go to the 
laryngeal muscles and control phonation : the act of deglutition is also 
affected by the nerve, which further affords the chief but not the only 
supply of the sterno- mastoid and trapezius muscles. Paralysis of the 
ster no -mastoid muscle causes slight elevation of the chin, with rotation 
towards the paralyzed side, causing an oblique position of the head. 
There is difficulty in depressing the head towards the paralyzed muscle, 
whose normal outline in the neck is also softened. If both muscles are 
affected, the head is held straight, and is rotated with great difficulty 5 
great difficulty is also experienced in depressing the chin. Paralysis of 
the trapezius muscle is shown by sinking of the point of the shoulder, 
by drooping downward of the scapula, the inferior angle of which is in 
the relation of adduction to the spine as compared with its fellow, and 
by prominence of the clavicle and supraclavicular space. If there is 
also difficulty in raising the scapula and clavicle and in elevating the 
arm, the upper fibres of the muscle are especially involved ; while if 
the scapula is not easily approximated to the spinal column, the middle 
and lower fibres are chiefly affected. If after complete paralysis of the 
trapezius there is absolute inability to draw the scapula towards the 
spine, palsy of the rhomboideus major and rhomboideus minor muscles 
may be inferred. Under similar circumstances, loss of the power of ele- 
vating the scapula and of moving the neck after fixation of the scapula 
indicates paralysis of the levator anguli scapulae. 

Long Thoracic Nerve. — If the scapula is drawn upward with its 
lower angle approximated to the spine, and if during the act of elevating 
the arm the lower angle of the bone does not describe an arc outward, as 



ORGANIC DISEASES OF THE NERVES. 



599 



it normally should, but approaches still nearer to the spine, while the 
vertebral border stands out in a wing- like manner, leaving a well-marked 
depression between it and the thorax, there is paralysis of the serratus 
magnus, which is supplied by the posterior thoracic or long thoracic or 
external respiratory nerve of Bell. 

Subscapular Nerves. — Difficult adduction of the arm, with loss of 
the normal power of depressing it and drawing it backward, especially 
in the act of placing the hand in contact with the buttock, shows paral- 
ysis of the latissimus dorsi muscle, which is chiefly supplied by the sub- 
scapular nerves. Inability to perform properly inward rotation of the 
humerus, diminished power of pronation, excessive outward rotation of 
the upper arm, and consequent faulty position of the hand, denote paral- 
ysis of the subscapularis and teres major muscles, which receive their 
nerve-supply from the subscapular nerves. 

Suprascapular and Circumflex Nerves. — Impaired power of out- 
ward rotation of the humerus, and consequent difficulty in performing 
such acts as writing, drawing, and especially sewing, in which this move- 
ment is essential, together with excessive inward rotation, even to the 
point of turning the ulnar border of the hand uppermost, indicate pa- 
ralysis of the important external rotator of the humerus, the infra- 
spinatus muscle, as well as of its assistant, the teres minor muscle. The 
former is supplied by the suprascapular nerve, and the latter by the 
circumflex. 

When the arm cannot be directly elevated, — i.e., brought at right 
angles with the trunk, — but hangs helpless close to the thorax, and, later, 
when a definite space appears between the head of the humerus and the 
acromion, there is paralysis of the deltoid muscle, which is supplied by 
the circumflex nerve. Anaesthesia of the skin is not always present. 

Anterior Thoracic Nerves. — Inability to adduct actively the arm so 
as to draw it across the chest or to place the hand on the opposite shoul- 
der, abnormal prominence of the ribs and intercostal spaces, and loss of 
tension of the anterior border of the axillary space, are the symptoms 
which show paralysis of the pectoralis major and pectoralis minor mus- 
cles, supplied by the anterior thoracic nerves. 

Musculo-Cutaneous Nerves. — Absence of the greater part of the 
power to flex the forearm, with loss of some of the power of supination, 
and partial lack of ability to draw the humerus forward, inward, and 
towards the scapula, points to paralysis of the group of muscles supplied 
by the musculo cutaneous nerve, — viz., the biceps cubitis, the coraco- 
brachialis, and part of the brachialis anticus. 

Musculo- Spiral Nerve. — If the hand hangs at right angles to the 
forearm (wrist-drop) and the power of extension at the wrist-joint and 
elbow-joint is absent, with the hand in pronation, the fingers bent, and 
the thumb flexed and adducted, the deformity is characteristic of the 
group of muscles supplied by the musculo -spiral nerve and its posterior 



600 



DISEASES OF THE NERVOUS SYSTEM. 



interosseous branch, — viz., the triceps and anconeus, the supinator lon- 
gus, the extensor carpi radialis longior, the extensor carpi radialis bre- 
vior, and all the extensor muscles of the superficial and deep posterior 
brachial regions. Other prominent symptoms are that the effort at ex- 
tension of the fingers is possible only in the second and end phalanges, 
while the first phalanges are more flexed (the interossei flexing the first 
phalanges and extending the others). The hand- grip is weakened unless 
the wrist-joint be put into extension, and when the hand and the forearm 
are put prone upon the table there is diminished power of abduction and 
adduction. The forearm cannot be brought midway between pronation 
and supination, and when it is in this position the ability to perform 
elbow-joint flexion is impaired. Finally, the forearm cannot be ex- 
tended upon the arm. Numbness and tingling may exist, but complete 
anaesthesia is very rare. 

Median Nerve. — Loss of the power to flex all the second phalanges 
and the end phalanges of the index and middle fingers, preservation of 
this motion in the first phalanges (interossei), and its partial preservation 
in the two outer fingers, inability to flex the thumb or to bring it in ap- 
position with the little finger, diminished power in flexing the wrist, 
which, when this is attempted, throws the hand into a marked adduc- 
tion, and impaired pronation with lessened sensibility of the first two 
fingers and the radial side of the ring finger, indicate paralysis of the 
median nerve. This nerve supplies all the flexor and pronator muscles 
of the deep superficial and anterior brachial region, with the exception 
of the flexor carpi ulnaris and the ulnar half of the flexor profundus 
digitorum, which are supplied by the ulnar nerve, and also all the mus- 
cles of the thumb except the adductor and one head of the flexor brevis 
pollicis, and finally the two outer lumbricales. Sensory fibres supply 
the radial side of the palm, the front of the thumb, the first two fingers, 
half of the third finger, and the back of these three fingers. 

Ulnar Nerve. — Imperfect flexion of the hand, which is drawn 
towards the radial side ; impaired power of adduction of the hand ; 
lessened ability to separate the fingers (abduction) or to bring them 
together (adduction) ; absence of the power to flex the first row of the 
phalanges and extend the other two rows ; almost entire immobility of 
the little finger ; difficulty in opposing the thumb to the metacarpal bone 
of the index finger, with disturbed sensation of the entire little finger 
and the ulnar side of the ring finger, constitute the symptoms of paralysis 
of the muscles supplied by the ulnar nerve. These muscles are the 
flexor carpi ulnaris, part of the flexor profundus digitorum, the inter- 
ossei, and the two inner lumbricales, all the muscles of the little finger, 
and the adductor of the thumb and one head of the flexor brevis pollicis. 

When the interossei and lumbricales are no longer able to flex the first 
row of the phalanges and extend the other two rows, but the extensor 
communis digitorum excessively extends the first row of the phalanges, 



ORGANIC DISEASES OF THE NERVES. 



601 



while the flexor muscles bend the second and third rows, the condition 
of " claw-hand'' is produced, which may mean paralysis of the ulnar 
nerve just above the wrist, so that the innervation of the interossei and 
lumbricales alone is affected. Affections of the ulnar nerve produce 
sensory disturbance of the ulnar side of the hand, two and a half fingers 
on the back, and one and a half fingers on the front. 

Spinal Nerves. — If the head hangs forward and cannot be extended, 
or at least can be extended only by the aid of a swinging motion, there is 
paralysis of the extensors of the cervical vertebrae, — i.e., the rectus capi- 
tis posticus major, the rectus capitis posticus minor, the upper portion 
of the trapezius, and the splenii. 

When the spine tends to assume a posterior curvature, most marked 
in the dorsal region, and the patient presents the appearance of "old 
man's back," in which he cannot voluntarily straighten the curvature, 
although this may be done by passive action, there is paralysis of the 
extensor muscles of the back, chiefly the longissimus dorsi and sacro- 
lumbal, with the condition of paralytic kyphosis. The production of 
lateral curvature, or paralytic scoliosis, means that the paralysis is limited 
to one side. 

When a patient carries the body with the upper portion bent back- 
ward, so as to throw it behind the centre of gravity, and when the body 
if inclined too far anteriorly falls forward and cannot again assume the 
erect posture until the hands, being placed upon the legs, help the arms 
by a sort of climbing process to bring the body again to its backward 
posture, the condition of paralysis of the extensor muscles of the lumbar 
region obtains, — i.e., the erectores spinas. In this condition the patient 
further stands with the head bent forward, walks with a swaying motion 
of the trunk, and when he sits down the upper part of the body appar- 
ently sinks, so that the dorsal spine is bent (kyphosis), while there is 
a deep concavity of the lumbar spine (lordosis). The nerves concerned 
in these palsies of the back are the posterior branches of the spinal 
nerves, cervical, dorsal, or lumbar, according to the region involved. 

Ilio-Hypogastric, Ilio-Inguinal, and Intercostal Nerves. — In- 
ability to compress properly the contents of the abdominal cavity, so 
that such acts as urination, defecation, and vomiting are performed 
with difficulty, and diminished power in the effort of respiration, to- 
gether with a tendency to fall backward when the upper part of the 
trunk is inclined posteriorly, show paralysis of the abdominal muscles, 
which are supplied by the ilio inguinal, ilio hypogastric, and lower 
intercostal nerves. 

Anterior Crural Nerve. — Loss of the power to flex the thigh upon 
the abdomen and extend the leg at the knee, and impaired ability to raise 
the body from the recumbent posture and to perform the acts of walking, 
running, going up stairs, and the like, are the symptoms which indicate 
paralysis of the group of muscles supplied by the anterior crural nerve, 



602 



DISEASES OF THE NEEYOUS SYSTEM. 



— viz., the iliacus, the pectineus, and all the muscles on the anterior 
surface of the thigh except the tensor vaginae femoris. 

Obturator Nerve. — When the act of pressing the knees firmly to- 
gether, or of crossing one leg over the other, cannot be properly per- 
formed, and when there is impaired power of external rotation of the 
thigh while in the sitting posture, the indications are that there is paral- 
ysis of the gracilis and adductor muscles of the internal femoral region 
and of the external obturator muscle, which group is supplied by the 
obturator nerve. 

Superior and Inferior Gluteal Nerves. — Uncertainty in the act of 
walking or standing, together with loss of power of internal rotation 
of the thigh and impaired power of external rotation, difficulty in ab- 
ducting the thigh, with disturbed relation of the thigh to the pelvis, 
and inclination of the latter to the opposite side during attempted action 
on the part of the affected limb, are the symptoms which point to paraly- 
sis of the muscles supplied by the superior and inferior gluteal nerves. 
The inferior gluteal nerve is distributed to the gluteus maximus, which 
muscle can forcibly extend the thigh on the pelvis and perform outward 
rotation of the thigh. The superior gluteal nerve passes to the tensor 
vaginae femoris and to the gluteus medius and gluteus minimus. The 
anterior fibres of these latter muscles rotate the thigh inward, whilst 
their posterior fibres rotate it outward. The muscles of the gluteal 
group when they take their fixed point from the pelvis are abductors 
of the thigh ; when they take their fixed point from the femur they 
support the pelvis on the femur. The tension of the fascia lata, which 
may be slackened in palsy, is usually maintained by the gluteus maximus 
and the tensor vaginae femoris. 

Sciatic Nerve. — Inability to flex or bend the knee, to oppose resist- 
ance to passive extension of the knee, and to raise the heel towards the 
buttock, would show loss of power in the semimembranosus, semitendi- 
nosus, and biceps femoris muscles, a group supplied by the great sciatic 
nerve. This is a possible form of paralysis ; but more usual are the 
palsies which occur from affections of the principal branches of its dis- 
tribution, and consist in loss of the extension and flexion of the foot and 
toes and abduction and adduction of the foot. 

External Popliteal Nerve. — If the foot cannot be flexed or abducted, 
nor completely adducted, and hangs downward, so that the patient in the 
act of walking raises the foot by flexing the hip -joint and then places it 
again upon the floor in such a manner that the point of the toes and the 
outer border of the foot touch the ground first, the symptoms are charac- 
teristic of paralysis of the muscles supplied by the external popliteal or 
peroneal nerve. This nerve, through its two branches, the anterior tibial 
and the peroneal cutaneous, supplies the muscles of the anterior portion 
of the leg and the extensor brevis digit or um on the dorsum of the foot. 
Its sensory fibres go to the outer half of the leg, to the dorsum of the foot, 



ORGANIC DISEASES OF THE NERVES. 



603 



and to the toes, except the outer side of the little toe and the adjoining 
sides of the great and the second toe. 

Internal Popliteal Nerve. — If the foot cannot be extended, nor the 
toes flexed or moved laterally, and if the patient cannot stand upon 
his toes or properly adduct the foot and raise its inner border, paral- 
ysis of the group of muscles supplied by the internal popliteal nerve 
and its continuation, the posterior tibial nerve, may be inferred. This 
group consists of the muscles of the calf and of the deeper posterior leg- 
region, and, through the external and internal plantar nerves, of those 
of the sole of the foot. In this palsy the great toe can neither be flexed 
nor moved from side to side. The foot may assume an appearance similar 
to the "claw-hand" described under palsy of the ulnar nerve, and for 
the same reasons. The external or short saphenous branch of the in- 
ternal popliteal sends sensory fibres to the outer side of the foot and 
the little toe, whilst the posterior tibial supplies the heel and the sole 
of the foot. 

NEURITIS. 

Neuritis is divisible into simple neuritis or perineuritis, multiple 
neuritis, and mesoneuritis. Of these forms simple neuritis and multiple 
neuritis are especially related, because in their clinical manifestations 
the cases grade into one another, and because the two disease processes 
may apparently coexist in one nerve-trunk and give a mixed lesion. 

Pressure Palsy. — Although the lesion is probably not a true neu- 
ritis, at this point may be considered the paralysis which follows con- 
tinuous pressure upon the nerve. Any nerve of the body may be 
affected, but in the ordinary form of the disorder the musculo- spiral of 
the arm suffers. The common cause is pressure by the head upon the 
arm during the sleep of drunkenness, or occasionally in the newly mar- 
ried. The chief symptoms are marked numbness and tingling, without 
great pain, and loss of power in the tributary muscles. 

The treatment consists of massage, faradization of the muscles, and 
in extreme cases hypodermic injections of strychnine into the affected 
muscles. The prognosis is absolutely favorable. 

The functions of a nerve may also be suspended by violent blows, and 
it is probable that from such cause the peripheral nerve-endings in 
the muscles especially suffer. The circumflex nerve with the deltoid is 
the most commonly affected, because the points of the shoulders are so 
often hurt in falling. The treatment should be leeching, fomentations, 
lead- water and laudanum, until the immediate effects of the bruise have 
subsided, followed by the use of electricity and massage. 

NEURITIS. PERINEURITIS. 

Definition. — An inflammation which primarily attacks the sheaths 
and connective tissue of nerves, and usually is confined to a single nerve 
or a very few nerves. 



604 DISEASES OE THE NERVOUS SYSTEM. 

Etiology. — Simple neuritis may be the result of injuries to the 
nerve, of extension of inflammation from diseased neighboring parts, 
of exposure to cold (this form probably rheumatic), and of the action 
of the rheumatic and certain other poisons. Toxic neuritis (except the 
rheumatic) is, however, usually of the multiple type. 

Pelvic neuritis is not rare after childbirth. It may be septic, but 
more often is a direct result of an injury to the pelvic nerves by the 
forceps or by the head of the child. 

Morbid Anatomy. — Simple neuritis is a neuritis affecting primarily 
the sheath and extending to the connective tissue between the fibres. 
The nerve is red, swollen, and infiltrated throughout with leukocytes. 
The nerve-fibres are finally invaded, the nuclei of the sheaths increasing 
greatly in number, and the axis- cylinders becoming varicose and at last 
disintegrating into a granular debris. The process continuing may end 
in the complete destruction of the nerve. 

Symptomatology. — The symptoms of neuritis are pain, tenderness, 
and disturbances of motion, sensibility, and nutrition. The pain is shoot- 
ing or burning, and follows closely the distribution of the nerve affected. 
It is persistent, with paroxysmal exacerbations, and is greatly increased 
by pressure and by active or passive movements. Early in the attack 
there is hyperesthesia, usually over the whole nerve distribution ; later 
there are losses of general sensibility, and in rare instances analgesia. 
In most cases atrophy of the muscles develops very slowly, but it may 
finally be complete. It is accompanied by changes in the electro-con- 
tractility of the muscles, reaction of degeneration, and even complete 
loss of galvanic contractility. There is a true loss of power in the mus- 
cles, which in the early stages may be entirely merged in the complete 
immobility produced by excessive pain. Pronounced trophic disturb- 
ances may occur in any or all of the tissues supplied by the nerve. 
Herpetic, bullous, or eczematous irritations appear, but more charac- 
teristic is the so-called glossy skin, in which the surface of the skin 
has a very fine, almost silky appearance, with pronounced glossiness and 
loss (especially apparent about the hands) of the normal lines and 
creases. These changes are associated with local rise of temperature, 
excessive sweating, alteration of the hairs, which are sometimes enor- 
mously developed, irregularity in the growth of the nails, and defor- 
mations involving changes in the bony structure, especially about the 
small joints. 

Simple neuritis may exist for years without destruction of the nerve, 
but in rare cases it finally gives rise to paralysis with atrophy and con- 
tractions of the muscle, anaesthesia, and other disturbances of sensation ; 
complete relief from pain seems almost never to come. 

Diagnosis. — The only disorder with which a simple neuritis could be 
confused is neuralgia, but in the latter affection there are no marked ten- 
derness of the nerve-trunks, no excessive pain on passive movements, no 



ORGANIC DISEASES OF THE NERVES. 



605 



loss of motor power, and no trophic changes in the muscles, skin, nails, 
etc. 

Prognosis. —The prognosis of simple neuritis is always serious, unless 
the lesion be due to rheumatism or other cause which can be readily 
overcome. The more severe the symptoms, especially the more pro- 
nounced the trophic lesions, the less the probabilities of rapid cure. 

Treatment. — When a cause can be assigned for a neuritis and is 
amenable to treatment, such treatment should be vigorously carried 
out. Thus, the salicylates should be given in large doses in a rheumatic 
neuritis, the iodides in a syphilitic neuritis, etc. So far as the neuritis 
itself is concerned, there is no reason for believing that drugs are directly 
effective. The general health must, of course, be sustained, and anodynes 
as necessary given for the relief of pain. Absolute rest of the part must 
be enjoined ; with it should be associated free counter- irritation by means 
of blisters, which are to be repeated from time to time almost indefi- 
nitely. In the very onset local bleeding by means of leeches may be of 
value. In some cases the continued application of cold by means of ice 
or of cold water is of service, but, as this measure is very capable of 
doing harm, it must be tried with caution. In other cases warm or 
even hot water gives the greatest relief. In our experience the imme- 
diate effect upon the patient of these applications affords a true index 
of their usefulness. 

In the beginning of the attack no form of electrical treatment should 
be employed $ later, great relief may sometimes be obtained by passing 
towards the periphery of the nerve a continued electrical current, of 
such strength as not to cause distinct pain. It is essential that it be 
passed uninterruptedly from ten to thirty minutes once or twice a day. 
When the electrical current does good in these cases it almost invari- 
ably relieves pain during its application ; if it increases the pain it is 
almost certain to do harm. The faradic current usually increases the 
pain and is distinctly injurious, but in a few cases in which the symp- 
toms are very lethargic it is of service. 

Early in the attacks massage is very painful and of exceedingly 
doubtful utility, though temporary relief and perhaps permanent good 
may be obtained by the most gentle effleurage 5 later, when there is no 
activity of inflammatory processes, and when the nerve-sheaths are full 
of exudation, cautious, careful massage may do great good, although it 
produces pain at the time of the application. 

PARENCHYMATOUS NEURITIS. MULTIPLE NEURITIS. 

Definition. — A peculiar degeneration or inflammation which at- 
tacks especially the nerve-fibres, and usually involves numerous nerves 
at one time. 

Etiology. — Multiple neuritis may be produced by a poison, or may 
occur during certain dyscrasiae and diseases of the nerve-centres. In 



606 



DISEASES OF THE NERVOUS SYSTEM. 



rare cases it arises without obvious cause aud is spokeu of as sponta- 
neous. The most common cause is alcohol, but the disease may be due 
to lead, arsenic, mercury, antimony, and other metallic poisons, or to 
various non-metallic poisons, among which may be mentioned carbonic 
oxide, sulphuret of carbon, sulphuretted hydrogen, sewer gas, and phos- 
phorus : it is probable that the cases which follow infectious diseases, 
such as diphtheria, small-pox, typhus or typhoid fever, spotted fever, 
sepsis, beri-beri, etc., are caused by autochthonous poisons. Even when 
due to dyscrasie such as occur in diabetes, phthisis, and cancer, it is 
probably of toxic origin. Sometimes in old people it is the first symp- 
tom of dry gangrene, when it is probably due to disturbance of the 
blood-supply of the nerves by atheromatous obstruction. 

In organic diseases of the nerve-centres, notably locomotor ataxia, 
parenchymatous neuritis is often a late complication ; on the other hand, 
it sometimes precedes the coming on of the central disease ; so that 
there is plausibility in the theory which assigns the diseases of the 
centre and of the nerves to the action of a common irritant poison. 

Morbid Anatomy. — The lesions of parenchymatous neuritis re- 
semble those which follow section of the nerve. The nuclei of the sheath 
of Schwann proliferate freely, the myelin becomes swollen and finely 
granular, and the axis- cylinders themselves grow granular, deformed, 
swollen, varicose. The sharp line between the two parts of the fibre 
disappears, and the nerve-fibre finally consists of debris in the sheath 
of Schwann. Earely is the lesion uniform along the nerve, and it may 
exist in segments separated by an almost unaltered nerve, constituting the 
segmentary neuritis of Gombault. In some cases along with the changes 
which have been noted there is free proliferation of the connective tissue 
of the nerve and of its sheath, forming what must be looked upon as a 
mixed type, uniting parenchymatous with simple neuritis. 

The muscles supplied by the affected nerve undergo a degeneration 
in which the fibrille shrink, become fatty, and finally disappear. 

Symptomatology. — In its most malignant form acute multiple neu- 
ritis commences abruptly with a chill, great prostration, and high fever, 
accompanied by violent fnlgurant or burning pains, formication, numb- 
ness, paresthesia, and hyperesthesia. The loss of power which is mani- 
fested from the first usually develops simultaneously in two or sometimes 
in all four extremities, especially affecting the muscles of the hands and 
arms and those of the legs proper. Rapidly the palsy creeps towards 
the trunk, and at the same time hyperesthesia passes into the loss of 
all forms of sensibility, constituting an anesthesia dolorosa, which may 
affect the skin before it does the deeper tissues, so that there arises 
a pathognomonic association of complete loss of sensibility in the skin 
with excessive sensitiveness of the muscles and other deep structures* 
Involvement of the nerves of the trunk may give rise to a pronounced 
girdle sensation. The trigemini usually escape, but may be involved. 



ORGANIC DISEASES OF THE NERVES. 



607 



The nerves of special senses may also be implicated, with resultant 
partial blindness and deafness and loss of taste, whilst double vision 
and irregular pupils show that the oculo-motor or other eye-nerves are 
affected. As the paralysis spreads, speech and swallowing become in- 
volved, and finally death may occur in forty-eight hours from respiratory 
paralysis. If the patient live, trophic changes show themselves in pig- 
mentation and thickening of the skin, in eczematous eruptions, in alter- 
ations of the nails, and even in oedema and bed-sores. The muscles 
waste early, and the reaction of degeneration soon appears. The deep 
reflexes are early abolished, but the sphincters are rarely if ever affected. 

In some very acute cases of polyneuritis the disturbances of sensation 
are very slight, the symptoms being those of an ascending paralysis. 
There are probably, however, always more numbness, tingling, and 
tenderness, especially over the nerve- trunks, than in true Landry's 
paralysis. 

In chronic multiple neuritis there is a symmetrical loss of power in 
the extremities, slowly increasing through many weeks without much 
pain, and little by little putting on the trophic symptoms of the fully 
formed disease. In the full cycle of its development such a case may 
last for years, passing through an initial stage, a progressive stage, a 
stage of standing still, and a stage of regeneration, and terminating in 
an after- condition of more or less impaired function. In such cases 
motion usually suffers much more markedly than does sensation. Often 
the first evidence of recovery is the ability of the patient by a strong 
effort of the will to make movements in the muscles, which are, how- 
ever, so weak that they do not affect the parts supplied. The anal 
sphincter and the bladder are very rarely attacked. Girdle pains are 
extremely infrequent. When present, they probably depend upon de- 
generation of a nerve of the trunk. In some cases coordination may 
be lost long before muscular power, and a pronounced retardation of 
sensation has been noted. Very frequently in severe cases there are 
marked psychical disturbances, with a strong depression of intelligence 
and of memory. 

Any of the nerves may be attacked, but the hypoglossal, the spinal 
accessory, and the glosso-pharyngeal rarely suffer, unless it be in the 
diphtheritic form of neuritis. It is extremely unusual for the nerves of 
special sense to be implicated. The usual course of the disease from the 
centre to the periphery is said to be sometimes reversed. 

Between the two extremes of the very acute and the very chronic form 
of polyneuritis every grade occurs. As the symptoms correspond in 
some degree with the cause, the following etiological varieties may be 
recognized : 

Alcoholic Neuritis. — Although alcoholism is much more common 
in men than in women, alcoholic neuritis appears to be more frequent 
in women. It is usually of slow development, the loss of power being 



608 



DISEASES OF THE NERVOUS SYSTEM. 



preceded by sensory symptoms, such as numbness and tingling, often ac- 
companied by excessive pain and painful cramps. The hands and feet, 
which are the first parts affected, are usually cold, often discolored ; urti- 
caria or other irritation, or glossy skin, may be present. The paralysis is 
mostly localized in the extensors. The course of the disease is usually 
essentially chronic, but there is an acute form in which death from respi- 
ratory paralysis may result in a few days. If the disease persists, con- 
tractures and deformities occur. Alcoholic neuritis is often associated 
with cerebral disturbances ; in the acute cases convulsions, delirium with 
hallucinations, mania, melancholia, and delusions occur, but they should 
be looked upon as due to alcoholism rather than as belonging to the neu- 
ritis, the brain and other nerve-centres in these cases suffering along with 
the peripheral nerves from the effects of the poison. 

Post-febrile Neuritis. — The neuritis which follows small-pox or 
other exanthematous disease most frequently attacks the legs, and is not 
rarely limited to the nerves of one leg. It is not commonly accompanied 
by much pain. (For diphtheritic neuritis, see Diphtheria.) The diabetic 
neuritis is apt to be accompanied by excessive pain, and in some cases is 
followed by rapid trophic changes, and even sloughing. Senile neuritis 
is usually accompanied by much greater sensory than motor disturbances. 
Its ordinary seat is the feet and the calves of the legs. 

Diagnosis. — Acute multiple neuritis is distinguished from Landry's 
paralysis and from acute poliomyelitis by the presence of sensory dis- 
turbances, and especially of tenderness of the nerve-trunks. Pain is said 
to be wanting in some cases of multiple neuritis, but if in any case there 
is no tenderness of the nerve trunks the diagnosis of multiple neuritis 
is not justified. We have seen cases of lead poisoning without fever, 
with wasting of the muscles, without disturbances of sensibility and 
without tenderness of the nerve-trunks, but with implication of the 
sphincters. The probability is that these cases are of spinal origin, a 
conclusion which is confirmed by the extraordinary benefit derived in 
them from the use of strychnine. Locomotor ataxia and peripheral neu- 
ritis frequently coexist. In such case neuritis is to be recognized by the 
nerve-trunk tenderness. Cases have been reported in which an ap- 
parently true ataxia has been proved by post-mortem to have been due 
to neuritis without spinal disease. The gait of neuritis usually differs 
from that of locomotor ataxia in that the loss of power in the extensors 
of the feet causes the legs to be lifted very high in order to avoid catch- 
ing the toes in obstacles (steppage gait of Charcot). 

Prognosis. — In malignant cases the danger of death is in direct pro- 
portion to the severity and rate of progress of the symptoms. Most cases 
of multiple neuritis recover more or less completely, but months and 
sometimes years are necessary. Cases produced by arsenic and other 
metallic poisonings often get well after the muscles have so far disap- 
peared as to yield no contractures to any stimuli. 



ORGANIC DISEASES OF THE NERVES. 



609 



Beri-beri. — This is an endemic disease of China, Japan, and various 
tropical countries, which has as its basal lesion a wide-spread periph- 
eral neuritis. As there are associated with this neuritis rapidly devel- 
oping anaemia, oedema, general anasarca, serous effusions, and in severe 
cases gastro-intestinal symptoms, suppression of urine, and a rapidly 
progressive exhaustion, it is plain that the disorder is not in its essence 
a peripheral neuritis, but a general disease whose nature remains very 
obscure. The discovery of a specific micrococcus has been asserted. It 
is said to have been almost driven out of the Japanese navy, where it 
was formerly particularly abundant, by an improvement of the rations. 
An epidemic of multiple neuritis which has been described as occurring 
on fishing-vessels upon the Grand Banks of Newfoundland has associ- 
ated with it oedema, shortness of breath, and great general failure, which 
suggest kinship with beri-beri. 

MESONEURITIS. 

Definition. — An inflammation of the nerve lymphatics. 

In 1881 Eenaut described a lymphatic apparatus within the sheath 
of the nerve-trunks, which, rudimentary in man, is completely devel- 
oped in the horse. In 1885 Varaglia first spoke of the occurrence of 
disease in this apparatus. Schultze subsequently gave detailed descrip- 
tions. The lesion has been noted as occurring in numerous diseases, 
as tabes, acromegalia, syringomyelia, acute multiple neuritis, myopa- 
thies, alcoholism, etc., but we have no clinical knowledge of symptoms 
produced by it. Mesoneuritis occurs in two forms: the nodular type 
consists of minute spheroidal masses in the centre of which is an amor- 
phous substance, while in the outer portion are swollen, granular, endo- 
thelial cells with nucleated corpuscles ; the lamellated type consists of 
plaques composed of thickened lamellae analogous to those constituting 
the sheath. We have no distinct knowledge of the nature or etiology 
of these changes, which are supposed to be the result of local irritation. 

SCIATICA. 

Definition. — A perineuritis of the sciatic nerve. 

Any nerve-trunk may be attacked with inflammation, but neuritis 
of the trigeminal, the trifacial, and the sciatic nerves is so frequent and 
so important as to require special notice. 

Etiology. — Sciatic neuritis may be produced by any of the causes 
of nerve inflammation heretofore enumerated. In its ordinary form it is 
a gouty or a rheumatic affection. It is frequently produced by exposure, 
and is more common in men than in women. 

Symptomatology. — The one prominent symptom of sciatica is pain, 
increased by movement, both passive and active, and also by pressure, 
especially upon the nerve-trunk. Hyperaesthesia, and later anaesthesia, 
are almost constant phenomena in bad cases. The pain is more or less 

39 



610 



DISEASES OF THE NERVOUS SYSTEM. 



constant, but often occurs in paroxysms of great intensity, and, whilst it 
may affect the whole or any part of the distribution of the nerve, is 
especially referred to certain points. These are the lumbar (origin of 
the nerve) ; the posterior sacro-iliac, roots of the sacral plexus ; the tro- 
chanterian, issue of the nerve between the trochanter and the ischium; the 
popliteal ; the patellar, terminations of the external popliteal branches ; 
the peroneal, situated at the head of the peroneal group ; the internal 
malleolar, internal popliteal and posterior tibial nerves ; and the external 
malleolar, saphenous nerve. Of these points the most important are the 
trochanterian, the popliteal, and the malleolar. In some cases there are 
also pain centres in the ankle, especially the inner side, and in the dorsum 
of the foot. At the painful points there is usually marked tenderness. 
Spasms of the muscles may be severe ; they often attend violent par- 
oxysms of pain, or may be produced by attempts at movement : in rare 
cases they are clonic and so frequent as to constitute a tic. Herpetic and 
other acute trophic disturbances are unusual, but in protracted cases 
the muscles undergo atrophy with contractures. Debove has called 
attention to polyuria as a symptom of sciatica : how far this excess of 
secretion is due, as he believes, to a general increase of the blood-pressure, 
and how far it is neurotic, is not certain. Every degree of sciatica in 
regard to severity and chronicity occurs. 

In 1888 Charcot called attention to scoliosis as a secondary result of 
a long- continued sciatica ; usually the concavity of the bend is opposite 
the sciatica, and has evidently been produced by the natural tendency 
of the body to bend towards the supporting leg in standing upon one leg. 
In rare cases the bend is towards the sciatica ; it is possible that spasm 
from involvement of the sacral nerves may in some cases be the cause of 
this, but such a scoliosis would be produced by habitually standing with 
the painful leg half crossed, its foot resting upon the other. 

Diagnosis. — Usually its unilateral character separates the pain of 
sciatica from spinal pains ; but even in double sciatica the tenderness and 
pain on movement render the diagnosis easy. 

Prognosis. — The prognosis in rheumatic sciatica is usually favor- 
able ; but in old cases it should be guarded, especially if there be trophic 
changes. 

Treatment. — In the treatment of sciatica the first attempt should 
be to remove the cause. In rheumatic cases the ordinary hygienic treat- 
ment of the rheumatic diathesis should be practised : the salicylates 
should be used in very large doses, and may be followed by potassium 
iodide, which is, however, chiefly valuable when there is a syphilitic 
basis. In the immediate treatment of the sciatica, if the symptoms are 
severe, absolute rest is of the greatest importance : not only should the 
patient be put to bed, but the limbs should be placed between salt-bags 
or in an anterior splint in such a way as to secure immobility and yet 
allow local treatment. Even in old chronic cases entire rest for six 



ORGANIC DISEASES OF THE NERVES. 



611 



weeks often does great good. For the combating of the pain hypo- 
dermic injections of morphine with atropine may be practised in the 
immediate neighborhood of the nerve, and when brought in contact 
with the nerve-trunk often seem to exert more than a simple anal- 
gesic influence. In some cases the hypodermic injection of cocaine or 
of antipyrin upon the nerve brings relief. Even hypodermics of simple 
water are sometimes efficient. 

In the beginning of the treatment the patient should be thoroughly 
purged, and the bowels throughout should be kept loose, as a loaded 
rectum and congestion of the pelvic circulation may aggravate a sci- 
atica. In the acute disorder leeching is often of service, and the free, 
persistent use of blisters is in all forms of sciatica of the greatest im- 
portance. When there is febrile reaction the combination of aconite 
with morphine is often useful. When the symptoms are very acute 
even the lightest galvanic current often increases the pain ; but when 
they have in a measure been subdued the continued current should be 
tried. (See Peripheral Neuritis.) 

Great good may sometimes be achieved by passing a stream of water 
as hot as can be borne by the patient for a length of time down the 
back of the limb. In the more obstinate cases of the disease counter- 
irritation by means of the hot iron should be practised ; and massage 
and electricity may be of the greatest service. Whilst the nerve is 
very tender massage may readily do harm. Acupuncture has been 
practised with asserted great relief. Usually a chronic sciatica is a 
form of chronic rheumatism, and as such is to be combated by sul- 
phur baths, pine-needle baths, steam baths, etc. Oil of turpentine has 
a very old reputation in the treatment of the chronic disease. 

Congelation of the skin over the painful points by methyl chloride 
has been strongly recommended by Debove. Stretching of the nerve 
is justifiable only in cases of the greatest obstinacy ; in the majority of 
instances it fails, but brilliant results are occasional. Even the mild 
stretching obtained by forcible flexion of the thigh upon the body some- 
times seems to do good. 

NEURITIS OF THE FACIAL NERVE. BELL'S PALSY. 

For anatomical reasons, the facial nerve is extremely liable to sudden 
inflammation from exposure to cold, or from involvement in otitis or 
other contiguous disease, and frequently suffers complete loss of function 
by the pressure of exudation within the long bony canal. 

Symptomatology. — As the facial is a purely motor nerve, there is 
no pain accompanying the inflammation. The onset is usually sudden. 

In the course of a few hours the paralysis is complete, or nearly so. 
The face is strongly drawn towards the opposite side. The power of 
completely closing the eye is lost, because the orbicular muscle is not able 
to raise the lower lid. The wrinkles in the forehead and the various folds 



612 



DISEASES OF THE NERVOUS SYSTEM. 



of the skin, to which the face owes so much of its expression, entirely 
disappear or are greatly flattened out. The saliva is with difficulty 
retained. Articulation is distinctly impaired. Mastication is not inter- 
fered with, except by the difficulty in retaining the food between the 
teeth caused by the loss of power in the buccinator muscle. 

Bilateral facial paralysis, facial diplegia, or simultaneous palsy of 
both facial nerves, is exceedingly rare, though it is sometimes pro- 
duced by a long transverse lesion crossing the anterior half of the pons, 
or by a transverse lesion encroaching upon the facial nerves after their 
emergence. It is characterized by a fixed, immovable, expressionless 
countenance, a peculiar dropping of the angles of the mouth and col- 
lapsed appearance of the nostrils during inspiration, and a marked flap- 
ping in and out of the cheeks during respiration. The voice is usually 
nasal, and the articulation is very bad, owing to an impossibility of 
pronouncing labial consonants. There is excessive difficulty in retain- 
ing the food between the teeth, and the saliva in the mouth. 

There are three distinct positions at which lesions of the facial nerve- 
trunk may occur and produce characteristic symptoms. The first and 
most frequent is that in which the point of pressure is near the point of 
escape from the temporal bone. Under these circumstances the paralysis 
is limited to the muscles of expression. 

The second form of facial palsy is that in which the lesion is situated 
above the origin of the chorda tympani nerve, but on the distal side of 
the petrosal nerve. Under these circumstances, to the paralysis of ex- 
pression is added great diminution of the sense of taste in the anterior 
two-thirds of the tongue. 

In the third variety a lesion behind the ganglionic enlargement which 
gives origin to the third petrosal nerve causes loss of power in the 
muscles of expression, loss of taste, paralysis of the soft palate, as re- 
vealed by a depression of the arch of the palate upon the affected side, 
and a loss of power in the tensor palati muscle, so that the soft palate 
is drawn towards the normal side. At the same time the sense of hear- 
ing is generally abnormally acute, and the secretions of the parotid and 
submaxillary gland are deficient. 

Diagnosis.— The only difficulty in a case of peripheral facial palsy is 
to decide as to its cause. Paralysis from exposure usually involves only 
that portion of the nerve which is external to the bony canal, though 
the inflammation may extend backward into the canal. Complete periph- 
eral palsy of the whole nerve is in the great majority of cases due to 
disease of the bone, or to tubercular or syphilitic basal meningitis. 

Prognosis.— A facial neuritis can usually be cured if seen early, 
unless it be due to disease of the bone or other incurable affection. 
When the muscles fail entirely to respond to any form of electricity 
the prognosis should be guarded, and if the condition has lasted one 
month without marked improvement recovery is improbable. 



ORGANIC DISEASES OF THE NERVES. 



613 



Treatment. — Leeching may be practised within the first twelve 
hours of the onset of the disease. Afterwards small, repeated blisters 
should be applied to the back of the ear. Salicylates may also be 
given at first, and afterwards small doses of the iodides. Electrical 
treatment of the affected muscles should be begun very early, although 
at first it should be mild, for fear of irritating the nerve-trunk. That 
current should be selected which produces the greatest contraction of 
the muscle with the least pain to the patient. 

INFLAMMATION OF THE TRIGEMINAL NERVE. 

Etiology. — Acute trigeminal neuritis is commonly the result of ex- 
posure to cold. Chronic or persistent neuritis may be due to propa- 
gation from an inflamed tooth-pulp ; to pressure upon peripheral nerve- 
filaments by alveolar thickenings, especially in old people ; to syphilitic, 
cancerous, or other tumors ; to carious bones ; and to various obscure 
causes. 

Symptomatology. — The chief symptom in trigeminal neuritis is 
pain, which varies in seat and intensity according to the degree and 
amount of nerve involvement. In severe cases the suffering is intoler- 
able ; pains of the most furious character follow one another along the 
course of the nerves in incessant flashes for a few seconds or minutes 
and then abruptly cease ; the pains may be accompanied by clonic and 
tonic contractions of the muscles of the side of the face (tic-douloureux). 
In some cases paroxysms occur only a few times a day, but more fre- 
quently they repeat themselves at short intervals. The lower jaw and 
cheek are probably the most frequent seats of the pain ; somewhat more 
rarely are the branches of the upper maxillary and even of the ophthalmic 
nerves affected. Only in exceptional cases do the mucous membranes 
suffer ; but frightful burning, shooting, stinging, dartiug pains may be 
felt in the mouth, and become excessively severe as they run through the 
tongue. Often, impelled by an irresistible impulse to do something, or 
perhaps led by a slight feeling of relief, the patient, during the par- 
oxysms, incessantly rubs the affected part with the hand, either alone or 
with a handkerchief. Tenderness is usually pronounced. It may be 
exquisite, a touch or a draught of cold air serving to bring on violent 
pain. The hyperesthesia may affect the mucous membrane or the skin, 
but may be chiefly manifested at certain points to which attention was 
first called by Valleix. 

In the ophthalmic branch, the most important point is the supra- 
orbital foramen. Less commonly to be recognized are the palpebral 
points of the upper eyelid, the nasal on the nose, where the ethmoidal 
nerve emerges from the nasal cartilage, the inner angle of the eye, cor- 
responding to the supra trochlear nerve, and the parietal prominence. 
In the superior maxillary branch, the most important point is over the 
infra- orbital foramen ; next in order is that in the upper lip, then the 



614 



DISEASES OF THE NERVOUS SYSTEM. 



points in the gums or in the alveolar processes of the upper jaw. In 
the inferior maxillary branch, the point on the chin is the most fre- 
quent, next is one in front of the ear, while very inconstant and rarer 
are points on the lower lip, on the side of the tongue, and on the alveo- 
lar processes of the lower jaw. 

Diagnosis. — The pain of trigeminal neuritis cannot be distinguished 
from that due to other causes than inflammation. Keflex trigeminal 
pains of a severe type, though usually less severe than those of neuritis, 
have been recorded as being produced by injury to distant nerves, by 
various forms of intestinal parasites, by hemorrhoids and other rectal 
diseases, and by irritation of the reproductive organs, especially in 
women. The diagnosis of such a case rests upon the recognition and 
removal of the irritation. 

Trigeminal pains of a severe type are sometimes the result of a neu- 
ralgic temperament, or at least exist without its being possible to dis- 
cover any sufficient cause for their existence. The nature of such pains 
is to be recognized by their inconstancy, their shifting from one nerve 
to another, their presence in other nerves than the trigeminal, and the 
existence of a general neurotic temperament. In a large proportion of 
cases these so-called neuralgias are gouty. The most violent attacks of 
trigeminal pain may be of centric origin. In a case of H. C. Wood's 
they were the result of a cerebral hemorrhage. They frequently occur 
in elderly people, apparently as the result of changes in the nerve-centres 
due to interference with their nutrition by atheromatous vessels. In 
these cases the pain may be followed after a time by difficulty of swallow- 
ing or other symptoms which show that the motor as well as the sensory 
portions of the medulla are suffering. 

It is especially in these centric cases that the condition known as 
anaesthesia dolorosa exists, in which affection there is loss of sensibility 
with violent prosopalgic pains. It is true that an anaesthesia dolorosa 
may arise from a tumor which presses upon the nerve and simulta- 
neously produces an ascending neuritis and a loss of function in the part 
immediately involved in the pressure. Such cases are very rare, and 
their true character can be recognized only by discovering the tumor. 
It is very doubtful whether a complete anaesthesia dolorosa ever exists in 
simple trigeminal neuritis. 

It may be laid down as a working rule that neuritis exists whenever 
there is distinct tenderness of the peripheral filaments of nerve or of 
Yalleix points ; whilst the absence of such tenderness is equally con- 
clusive that the disease if organic must be centric, or else due to some 
morbid growth. 

Prognosis.— Acute trigeminal neuritis due to cold usually yields 
rapidly to treatment. Deep-seated chronic forms of the disorder are, 
however, very obstinate, and their prognosis is always serious unless 
some persistent cause can be found and removed. A large proportion 



ORGANIC DISEASES OF THE NERVES. 



615 



of the cases cannot be relieved except by a surgical operation, the effects 
of which are also uncertain. 

Treatment. — The treatment of trigeminal neuritis is in great part 
similar to that of inflammation of other nerves. (See page 605. ) Certain 
specific remedies have, however, been recommended, especially croton 
chloral, to which, with doubtful correctness, has been attributed a spe- 
cial anaesthetic action over the trigemini. It may be given in ascend- 
ing doses, commencing with five grains, three times a day. In our 
hands it has not given satisfaction. Amyl nitrite has been very highly 
recommended by Manzi and others, but the reports of the cases read 
like those of hysterical neuralgia : it may be given every two hours by 
inhalation in such doses as are necessary to produce flushing of the face 
and other physiological effects. Aconite and its alkaloid, aconitine, 
have been highly recommended by various authorities : half a milli- 
gramme of the crystallized aconitine of Duquesnel, or of the pure amor- 
phous aconitine, may be given three times a day, increased as high as 
six milligrammes if the patient can bear it. Great care, of course, must 
be taken, and the dose must be reduced so soon as lowering of the pulse 
or other physiological effect is apparent. In neuralgic cases large doses 
of quinine are often of great service. In gouty or syphilitic cases proper 
constitutional treatment usually brings relief. Freezing the face with 
methyl chloride is alleged to have cured some patients. 

Surgical interference is very frequent in trigeminal neuritis. As 
a very large proportion of cases begin in diseases of the teeth or the 
alveolar processes, it is extremely important that the local disease of 
these parts be surgically attended to with care in the earliest stages of 
the disorder. Whenever the fixity of the pain and of the tenderness in- 
dicates that one branch of the nerve is chiefly or solely affected, surgical 
interference should be prompt to prevent extension of the inflammation. 
In no case should simple section of the nerve be relied upon ; as long a 
piece as is practicable of the nerve should be destroyed by resection, by 
thermo- cautery, or by other means. In obscure cases, with wide-spread 
distribution of the pain, removal of the Gasserian ganglion, although ac- 
companied with some risk to life, is certainly a proper operation. 

Eemoval of the nerve almost invariably gives relief ; in a few cases 
it fails altogether ; frequently the pain returns after an interval of 
weeks or months of comfort, probably because there is a reunion of 
the nerve or the development of a neuritis above the point of section. 
When a trigeminal pain is due to disease of the nerve-centres, exsec- 
tion is of no value, and, if the diagnosis has been clearly made out, is 
an unjustifiable operation. 

NEURITIC MUSCULAR ATROPHY. 

Definition. — A disease characterized by a peculiar degeneration of 
the nerve-trunks, in many cases spreading to the spinal cord and pro- 



616 



DISEASES OF THE NERVOUS SYSTEM. 



during a very slow wasting of the muscles, accompanied by the ap- 
pearance of the reaction of degeneration. 

Synonymes.— Peroneal type of muscular atrophy j Charcot- Marie 
type of muscular atrophy. 

Etiology. — Neuritic muscular atrophy is a distinctly family disease, 
occurring very frequently in groups of cases in successive generations. 
In typical cases no cause can be assigned for the attack except heredity. 
But it has been alleged that the disease may be due to long- continued 
muscular strain, or to the effects of habitual pressure upon the affected 
part incurred in the daily occupation of the patient. Thus, in a man 
accustomed to carry heavy loads on his shoulders and neck the affection 
began in the shoulder and neck muscles. In a mason the muscles of 
the intra- metacarpal region and of the ball of the thumb of the left 
hand, with which he was accustomed to pick up stones, were the first 
affected. It is probable that these irregular cases are distinct from the 
hereditary typical disease, and represent really an accidental neuritis. 

Morbid Anatomy. — The characteristic lesion is a peculiar degener- 
ation of the intra muscular nerves, accompanied by the disappearance 
of their myelin and the hypertrophy of their sheaths. The individual 
muscle-fibres undergo atrophy, which is apparent before the loss of their 
striation ; finally they completely disappear. The intra-muscular vessels 
have their coats extremely thickened. The peripheral nerve-trunks, both 
sensory and motor, are usually much altered. No unmistakable lesion of 
the gray matter of the spinal cord seems to have been detected, whilst 
Dejerine, Dubreuilh, and others found the gray substance intact. The 
posterior columns have been so uniformly degenerated that Marinesco 
asserts that the spinal lesion is primary and that the nerve-lesions are 
secondary. 

Symptomatology. —The muscular atrophy commences in the feet, 
usually in the extensors of the great toe, and afterwards involves the 
common extensors and the peronei muscles. The small muscles of the 
feet may be early affected, and, as the disease begins usually in early 
childhood, a form of club-foot is frequently produced. The evolution 
of the disease is very slow, and it may be years before changes occur in 
the upper extremities : these usually begin in the hand. In the thenar, 
hypothenar, and interossei muscles they are often symmetrical, and result 
in the production of the claw-hand. The muscles of the trunk and of 
the face are very rarely, if ever, attacked. Fibrillary contractions are 
pronounced in the atrophied muscles, as is also the reaction of degen- 
eration. The knee-jerk is diminished or lost when the thighs are in- 
volved. Disorders of sensibility are frequently pronounced, but do not 
appear early. They consist of pains, especially of painful cramps, 
anaesthesias, and paresthesias. In only one out of twenty-five cases 
studied by Bernhardt did pain appear before the fifteenth year of age 
and the sixth of the disease. In about one- third of the cases it came on 



ORGANIC DISEASES OF THE NERVES. 



617 



between the ages of twenty and twenty-five. Distinct incoordination has 
been noted in various cases, and vaso-motor disturbances in the affected 
part, as shown by discoloration and coldness, are very common. 

In rare cases neuritic atrophy begins in the hands, and cases have 
been described in which other portions of the body were primarily af- 
fected ; but it is very doubtful whether such cases really represented 
the present disorder. 

Diagnosis. — Neuritic atrophy is distinguished from the true myopa- 
thies and from progressive muscular atrophy by the presence of the re- 
action of degeneration, of pain, and of other sensory disturbances, by 
the age of attack, and by its being a family disease. From muscular 
atrophies following parenchymatous neuritis it is distinguished by its 
being a family disease, by the age of attack, and by the peculiar method 
of its development. (See Etiology.) From syringomyelia it is at once 
distinguished by the absence of the peculiar disturbances of sensation 
and nutrition. The nature of those cases in which it has been alleged 
that the disease was produced by local cause (see Etiology) must, in the 
present state of our knowledge, be considered doubtful. 

Prognosis and Treatment. — Recovery never occurs, and there is 
no known effective treatment. 

NEUROMA. 

Definition. — Tumor involving a peripheral nerve. 

Etiology. — In many cases neuromata are traceable to injuries : thus, 
the bulbous nerves of amputation are the neuromata that produce pain- 
ful stumps. The fact that neuromata are sometimes multiple indicates 
that they may be due to a wide-spread vice of constitution. They may 
occur at any age and in either sex, although multiple neuromata are 
said to be very rare in women. Any nerves, either within or without the 
bony cavities, may be attacked. 

Morbid Anatomy. — Neuromata maybe divided into true neuromata, 
which consist of an abnormal growth of nerve-fibres, constituting an 
irregular mass, and pseudo-neuromata, various heterologous growths, 
such as fibroma, sarcoma, etc. True neuromata were subdivided by 
Virchow into the myelinic, consisting of medullated nerve-fibres, and 
amyelinic, consisting of non-medullated nerve-fibres. Neuromata may 
vary in size from that of a small bird shot to an inch in diameter. Plexi- 
form neuromata consist of interlacing neuromatous nerve- cords. They 
may be of great extent, but occur almost exclusively as a congenital 
malformation. 

Symptomatology. — Neuromata may be latent ; usually, however, 
they are accompanied by pain, which is referred to the distribution of 
the nerve, often very severe and not rarely paroxysmal. In most cases 
there are no motor symptoms, but the functions of the nerves may be so 
interfered with as to produce partial or complete paralysis of the tribu- 



618 



DISEASES OF THE NERVOUS SYSTEM. 



tary muscles. Eeflex spasms in adjacent or distinct muscles are not rare, 
and violent epileptiform convulsions may mark the peripheral irritation. 
Marked tenderness upon pressure is a frequent but not an invariable 
symptom. Pressure above the tumor on the nerve-trunk sometimes 
alleviates pain. A peculiar variety of neuroma is that known as tuber- 
cula dolorosa, in which various parts of the skin are covered with small, 
subcutaneous, painful tumors, which may be made up in great part of 
nerve-fibres or be largely composed of adenomatous or other tissue. 
Neuromata may be latent and produce no pain and give rise to no 
tenderness, so that if deep-seated their presence may not be suspected. 

Diagnosis. — A superficial neuroma cannot be overlooked if it causes 
symptoms. A deep-seated neuroma has often been unrecognized for a 
long time. Even if there be no evident local swelling, a nerve should be 
exposed and examined whenever there is a fixed pain of indefinite con- 
tinuance, not accompanied by the characteristic symptoms of a neuritis, 
not readily explained as the outcome of a local non-nervous disease, and 
not relieved by treatment. 

Treatment. — The only treatment for a neuroma is excision, which is 
permanent in its influence, as the tumors have no tendency to return. 

SYPHILIS OF THE NERVE. 

Gummous infiltration of the nerve-trunk may be the result of contact 
with a gummous tumor outside of the nerve, or in very rare instances 
may primarily develop in the nerve. The blood-vessel walls are first 
infiltrated with minute cells, which soon force their way through the 
trabecule of the nerve, cause atrophy of the nerve-fibres, and finally 
destroy the arteries themselves. In its full development the syphiloma 
contains round cells, spindle-shaped cells, fibrous structure, and the debris 
of nerve-elements, all enclosed in the greatly distended nerve-sheath. The 
point at which the nerve is attacked is almost always inside of the ver- 
tebra or of the cranium, and almost uniformly there are other large 
neighboring gumma. As gummous disease of the nerve without im- 
plication of the nerve-centres is very rare, the disease is usually accom- 
panied with complex symptoms. Complete abolition of the function of 
the nerve is very uncommon, so that trophic changes are extremely rare, 
and the loss of mobility or of sensibility is never complete. Spasm is 
sometimes present ; pain is commonly the chief manifestation. The tri- 
geminus nerve is, according to our experience, more frequently attacked 
than any other, the result being a specific tic-douloureux. 

The prognosis is favorable if the case be seen early. The treatment 
should be actively antisyphilitic. 



YASO-MOTOR AND TROPHIC DISEASES. 



619 



CHAPTEE VII. 

VASO-MOTOR AND TROPHIC DISEASES. 
RAYNAUD'S DISEASE. 

Definition. — A disease which in its acute form is composed of three 
stages, local syncope, local asphyxia, and local or symmetrical gangrene, 
and which in its chronic form consists of repeated paroxysms of one or 
more of these stages. 

Etiology.— Acute Eaynaud's disease, or symmetrical gangrene, occurs 
chiefly in young neuropathic subjects, and has been noted as a complica- 
tion of organic spinal diseases. It appears sometimes to be produced by 
violent emotional strain, especially by fright, but usually has no apparent 
exciting cause. 

Chronic Raynaud) s disease occurs also in neuropathic subjects, and has 
been especially noted in alcoholics and in opium-eaters. The individual 
paroxysms are often provoked by an exposure, either locally or generally, 
to cold, — in some individuals being confined to the winter months. Emo- 
tional excitement may produce an attack. 

Morbid Anatomy. — The basal pathology of Eaynaud's disease is 
entirely obscure. The peripheral neuritis found by Pitres, and the endar- 
teritis and endophlebitis noted by Von Dehio, were probably secondary 
lesions. The disorder has occurred so frequently in locomotor ataxia 
and syringomyelia as to indicate a spinal origin of the attacks. It is 
probable that the local syncope depends upon an obliterating spasm of 
the arterioles, and that the local asphyxia is the result of a complete 
vaso-motor paralysis. Violent spasms have been noted in the retinal 
artery during an attack. 

The clinical differences between the chronic and the acute form of 
Eaynaud's disease are in individual cases so great as to cause hesitation 
in considering them as one disease ; nevertheless, separation of the two 
affections would seem impossible in the face of the facts that every 
variety of paroxysm between the slightest "dead finger" or local syn- 
cope and the most acute gangrene exists, and that at any time, even 
after a lapse of years, the chronic form of the disease may end in acute 
gangrene. 

ACUTE RAYNAUD'S DISEASE. 

Symptomatology. — The first stage of acute Eaynaud's disease {local 
syncope) is sudden and usually painless in its onset. The skin of the 
affected part becomes of a dead- white color, sometimes even a little yel- 
lowish, and appears entirely devoid of blood. Cutaneous sensibility is 
lessened or altogether destroyed. Even when the sensation of contact is 



620 



DISEASES OF THE NERVOUS SYSTEM. 



entirely lost the power of distinguishing heat and cold may be retained. 
The temperature of the parts is very notably diminished ; the power of 
movement is lost. This condition may last for only a few hours, or as 
long as a month. When the second stage (local asphyxia) is reached the 
white color gives way to a cyanotic tint, which deepens to violet, and in 
some cases to black. Pressure on the parts now produces whiteness, 
followed by instant return of color on removal of the pressure, showing 
that the discoloration is owing to blood still inside of the capillaries. The 
parts are at this time swollen and much below the normal temperature. 
There is excessive burning pain, which may begin even before the con- 
gestion. The pain is more or less paroxysmal, occurring, it may be, in 
agonizing crises, which usually pass off with an abundant emission of 
urine. After some hours or days gangrene (local gangrene), sometimes 
but not always preceded by blebs containing bloody serum, rapidly de- 
velops. Sloughing may be complete in ten days from the beginning of 
the attack, but usually a longer time is required. 

During the whole process the bodily temperature is not altered, but 
even in the beginning failure of appetite, vomiting, and other abdominal 
disturbances are very common, whilst a peculiar apathy with irritability 
is almost characteristic. Transient loss of consciousness and epileptic 
seizures have been recorded. A wide-spread acute synovitis, with great 
swelling of the affected joints and the parts surrounding them, bleeding 
from the nose, hemoglobinuria, amblyopia, tinnitus aurium, partial 
deafness, anomalies of taste, irregularities of the pupil, aphasia, have 
all been noted, apparently results of disturbances of the circulation 
similar to but less pronounced than those occurring in the diseased 
parts. The gangrene is almost universally more or less symmetrical. 
Its especial seat is the ends of the fingers and of the toes, but the tip 
of the nose, the ears, the buttocks, or the muscles of the back may be 
affected. 

Diagnosis. — The only disease with which acute Raynaud's disease 
could be confounded is senile gangrene, from which it is distinguished by 
its occurring in young subjects, by its being symmetrical, and by the 
distinctness of the three stages of local syncope, local asphyxia, and 
gangrene. Difficulty may sometimes arise in deciding whether a case 
should be looked upon as the chronic or the acute form of the disorder. 
Usually the acute disorder can be recognized by the intensity and per- 
sistency of the symptoms, but sometimes it may be necessary to wait for 
the appearance of gangrene before giving a positive opinion. 

Prognosis. — Loss of tissue by gangrene seems to be invariable, but 
the amount of destruction is generally much less than would appear un- 
avoidable in the beginning. In most cases there is only a single attack 
of local gangrene ; but there may be repeated recurrences. 

Treatment. — There is no known specific medication in acute Ray- 
naud's disease. Tonics, analgesics, laxatives, bismuth subnitrate, and 



VASOMOTOR AND TROPHIC DISEASES. 



621 



other appropriate remedies may be used to combat symptoms as they 
arise. The affected part should be protected by wrapping, preferably in 
carded wool, and prolonged immersion in hot water may relieve pain. 
Galvanism has been recommended by Barlow, who applies it by immersing 
the part in a basin of warm salt water in which the negative electrode 
has been put, whilst the positive electrode is applied over the spine. It 
sometimes relieves pain. It is especially important to avoid local irri- 
tation ; but, when the slough has formed, carbolated cosmoline or other 
mild antiseptic dressing may be used. 

CHRONIC RAYNAUD'S DISEASE. 

Chronic Raynaud's disease consists of a series of paroxysms simu- 
lating those of the acute disease, but not ending in gangrene. There is 
usually a stage of local syncope, followed by one of local asphyxia, but 
the local asphyxia may occur without being preceded by local syncope. 
It was to cases of this character that Weir Mitchell especially gave 
the name of erythromelalgia. On the other hand, cases are not rare in 
which the local syncope may recur a great number of times without local 
asphyxia. 

During an attack of simple local syncope the parts are very white, 
shrunken, stiff, but usually free from pain and tenderness, except as the 
syncope is passing off, when the pain may be severe, even when there 
is no pronounced asphyxia. We have seen attacks of local syncope 
of the fingers accompanied by or sometimes replaced by violent henii- 
crania. Apoplectiform attacks, epilepsy, acute mania, amblyopia, and 
aphasia, with temporary hemiplegia, have been similarly noted. 

The disorder may persist for many years, causing much suffering, but 
having no effect upon life, and producing no loss of tissue ; or local sym- 
metrical gangrene may occur at any time, either affecting the parts deeply 
or else simply giving rise to blebs, ulceration, loss of nails, etc. Under 
appropriate treatment the disease may entirely disappear. The treatment 
must be primarily directed to building up the strength and health of the 
patient. Complete change of the habits of life, out-door exercise, nutri- 
tious, non-stimulating food, and other measures such as are used to com- 
bat neurasthenia, are essential. Antipyrin and allied drugs may be tried. 
When relations between cold and the attacks can be traced, absolute 
avoidance of exposure is essential, and change of climate may be very 
beneficial. If the disease occur in a narcotic devotee, the habit must be 
abandoned. 

PERFORATING ULCER. 

Definition. — A peculiar rapid ulceration, usually developed in the 
foot without obvious cause. 

Etiology. — Perforating ulcer occurs with comparative frequency in 
locomotor ataxia, has been noted not infrequently in neuritis or after 
section of the sciatic nerve (Morat), and is probably always of trophic 



622 



DISEASES OF THE NERVOUS SYSTEM. 



origin. In locomotor ataxia it may be one of the first indications of the 

disease. 

Symptomatology. — Usually, but not always, after a severe local pain, 
a small hemorrhagic or ecchymotic spot appears under the epidermis of 
the foot ; in the course of a few hours the skin detaches itself, or more 
frequently it becomes excessively thickened into a large, dry, corn-like 
mass ; a small slough soon separates, leaving the ulceration round, with 
sharp, acute edges, piercing, it may be, only through the skin, but usually 
to the deeper tissues, and even to the joint or bone. In most cases the 
bone becomes seriously diseased, when the lesion appears as a small aper- 
ture leading by a narrow sinus to diseased bone and surrounded by thick- 
ened superimposed layers of epidermis. The surface of the spot is usu- 
ally cold and anaesthetic, the characteristic feature of the ulcer being its 
insensibility to irritants and its freedom from pain during rest. Walking 
may cause suffering ; and the fulgurant pains of locomotor ataxia are very 
frequently present, but do not have their origin or focus in the ulcer. 
Erysipelatous inflammation or erythematous exudations are apt to occur, 
and may terminate in death. Except in the rare cases in which the ulcer 
heals early, the bones of the foot, and indeed all the tissues of the foot, are 
finally affected. The small joints frequently become inflamed and event- 
ually anchylosed, or undergo ulceration and destruction, resulting in lux- 
ations and deformities. The nails of the foot usually become brownish, 
dry, greatly thickened, curved, and furrowed. In some cases there is a 
marked increase in the growth of the hair and in the pigmentation of the 
leg, and the whole foot may be bathed in a peculiarly fetid sweat. 

Prognosis. — The prognosis is very unfavorable in proportion to the 
severity and immutability of the organic nervous disease producing the 
perforating ulcer. Barely the patient may escape with exfoliation of the 
bone. 

Treatment. — The treatment consists especially in the use of absolute 
rest, high feeding, massage, alcohol, etc., to build up the strength of the 
patient. (See surgical text-books. ) 

ANGIONEUROTIC CEDEMA. GIANT URTICARIA. 

Definition. — A circumscribed cedematous swelling of the skin, ap- 
parently of purely neurotic origin. 

Etiology. — Angioneurotic oedema occurs in neurotic individuals, 
the individual attacks being provoked by severe exposure, indigestion, 
great mental excitement, and other transient causes. In some cases it 
appears to be an hereditary family disease. 

Morbid Anatomy. — This affection seems to be a purely functional 
neurosis. As we have seen this disease alternate with attacks of urti- 
caria, and even grade into urticaria, the two affections are very closely 
allied, if indeed they are not one disease. 

Symptomatology. — The characteristic symptom is circumscribed 



VASOMOTOR AND TROPHIC DISEASES. 



623 



cedematous swelling, which, may involve both the skin and the mucous 
membranes, and gives rise to rounded elevations having a diameter of 
from two to eight inches, pale or sometimes deep red in color, coming and 
going, often, in the course of a few hours. In typical cases there is no 
itching or pain other than a slight burning ; but there may be intense 
itching, as in urticaria ; again, the wheals may at first be very small, as 
in true urticaria, but soon spread over a wide area. Not rarely they are 
symmetrical upon the two sides of the body. The affection is usually 
not serious, but at least one case has been noted with paroxysmal hsemo- 
globinuria, and death is said to have been produced by cedematous swell- 
ing of the glottis. In some cases there is marked gastro- intestinal irri- 
tation with the attack. 

Prognosis. — An obstinate affection, usually recurring for many years, 
sometimes reappearing month after month at the menstrual period. 

Treatment. — The most important part of the treatment .is that of 
the underlying bodily condition. The digestion should be especially 
attended to. Large doses of extract of ergot at times seem to do good ; 
antipyrin, phenacetin, and similar compounds we have seen act happily ; 
quinine in full doses has been especially recommended by Oppenheim. 

Intermittent Dropsy of the Joints is a rare disease, in which at inter- 
vals of from two days to several weeks a joint, usually the knee, sud- 
denly swells enormously, remaining pale, cool, and free from pain, and 
recovering the normal state in from three to eight days. The treatment 
is that of the neurasthenia or hysteria which always underlies the disease. 

Acro-Parcesthesia, or Night Palsy, is a disorder especially met with in 
women about the climacteric, in which there are persistent, often very dis- 
agreeable, paresthesias in the hands, and especially in the points of the 
fingers ; most pronounced at night, and in the morning when the subject 
wakes ; sometimes, but not usually, attended with pallor of the fingers. 
The affection continues indefinitely, but is chiefly important from the fact 
that its subjects often look upon it with great alarm as the precursor of 
paralysis. It has, however, no such significance, nor is it connected with 
weakness of the heart. 

SCLERODERMA. 

Definition. — A disease characterized by a cirrhotic hardening of the 
skin and subcutaneous tissues, followed by atrophy. 

Etiology. — Scleroderma is not hereditary. It occurs in every race 
and at all ages, about seventy per cent, of the cases being in women. It 
has been frequently attributed to exposure to wet and cold, and the local 
affection is said to have followed a prolonged immersion of the hands in 
cold water. Injuries of the surface, the irritation of mustard plasters or 
blisters, and infectious fevers are also alleged causes. 

Morbid Anatomy. — The lesion of scleroderma consists of a marked 
increase of the elastic and cellular tissues of the skin and other parts, with 
an infiltration with leukocytes and embryonal elements along the lines of 



624 



DISEASES OF THE NERVOUS SYSTEM. 



the blood-vessels. According to Unna, the lymph- vessels are narrowed 
and the lymph-spaces outside of the vessels are increased. When the 
bones are involved, leukocytes appear in the periosteum and even in the 
osseous tissue. Pigmentation of the skin is frequent, and broad, homo- 
geneous bands in the corium are said to be a characteristic alteration. 
The blood-vessels everywhere have their walls strongly thickened and 
finally undergo obliteration. The infiltration and hardening are followed 
by atrophy. No constant or peculiar changes have been found in the 
nerves. 

Symptomatology. — Scleroderma may be ushered in by distinct pro- 
dromes, such as fever, pains, paraesthesise, malaise, and a special feeling 
of weakness, accompanied by local cyanosis or diffused redness, or redness 
in spots, with or without swelling of the skin. The discolored skin soon 
becomes cedematous and often erysipelatoid. The oedema frequently dis- 
appears during the night, to reappear in the day, or it may persist stead- 
ily. The first or cedematous stage of the disorder may remain without 
change for two or even more years, and it is affirmed may be recovered 
from ; but in most cases the skin, sooner or later, gradually hardens so 
that the finger can no longer leave an impress. 

During the second or indurated stage of the disease the surface of the 
body is hard, light-colored, furrowed, and preserving the coarse and fine 
markings of the skin, or it may be entirely smooth. It may be dry or 
sweating, and often suffers from vaso-motor disturbances. It usually 
finally becomes excessively pigmented. Paresthesia and neuralgic pains 
are very common. Sometimes there is great tenderness, but anaesthesia 
more or less complete has been noted in a large proportion of the cases. 

The hardening may persist for many years, gradually involving the 
deeper tissues, and even the bones. The general health usually fails. 
Dyspepsia, albuminuria, and various nervous disturbances, such as loss 
of memory, hallucinations, insomnia, giddiness, headache, and epileptoid 
attacks, have been noticed. Finally, if the patient survive, the third 
stage, or that of atrophy of the parts, appears, ending in death from ulcer- 
ation and exhaustion, or more commonly from some complicating disease 
(especially pneumonia). Owing to the hardening and subsequent atrophy, 
the face in scleroderma is expressionless, and chewing and other motions 
are often interfered with. The mucous membrane of the mouth, pharynx, 
and vagina may be attacked, and an extraordinary narrowing of the 
laryngeal entrance is occasionally a troublesome complication. 

Scleroderma varies indefinitely in the duration and the comparative 
development of the different stages, and also in its distribution. In a 
collection of nine hundred cases, Lewin and Heller found that in sixteen 
per cent, the whole body was involved, in twenty-three per cent, the 
trunk, in twenty per cent, the head, in seventeen per cent, the lower 
extremities, and in thirty -two per cent, the upper extremities. 

Treatment. — All forms of salves, local applications, baths, etc., have 



VASO- MOTOR AND TROPHIC DISEASES. 



625 



been used in scleroderma, apparently without definite result. The sur- 
gical extirpation of the affected portion of the skin has also been tried, 
without distinct advantage. No internal medication is of value. The 
general health of the patient should be sustained, and, as there is usually 
great susceptibility to cold, the effect of a warm climate may be beneficial. 

Morphoea (keloid of Addison) is a local form of scleroderma in which 
the changes are not diffused, but occur in patches or bands of irregu- 
lar shape, and of a dead or old ivory-white tint, often bordered with a 
narrow violet, lilac, or pink zone of dilated vessels. When the band is 
narrow it may make a distinct sulcus. Cases occur in which diffused 
scleroderma occupies one portion of the body with morphoea patches on 
another. The diffuse disease in some instances has appeared before, in 
others after, the development of the patches. The most common local 
form of scleroderma is that in which the finger is attacked (sclerodactylia), 
with consequent great thickening and subsequent atrophy, even to the 
entire disappearance of the phalanges. 

Facial Hemiatrophy most frequently develops in childhood, but may 
occur at any age. It usually begins with pain, which is often severe, 
followed by progressive atrophy affecting the skin and the deep tissues of 
the face. The skin may be white or pigmented, evidently thinned, but 
still preserving its sensitiveness ; the hairs fall out, the bones waste, even 
the teeth drop out, from destruction of the alveolar processes. The prog- 
nosis is unfavorable, no known treatment having any effect upon the 
disease. As the disease is strictly limited to one side of the face, the 
contrast between the two sides is often very marked. Facial hemiatrophy 
is thought by some to be a trophic neuritis, but is more probably a local 
form of scleroderma. 

Allied to scleroderma are some of the skin atrophies, especially xero- 
derma pigmentosum, which begins usually in the second year of life with 
freckles, followed by telangiectases or nsevi, these by atrophy of the skin, 
with superficial ulceration, and after some years warty tumors with free 
discharge and marked pain, and in the end death from exhaustion. 

Sclerema neonatorum, a disease allied to scleroderma, but believed by 
most authorities to be distinct from it, occurs as a congenital affection. 
It is characterized by stiffness of the joints and jaws and by large areas 
of induration of the skin, which is tense and glossy, but does not pit on 
pressure. In most cases the disease spreads and a fatal result is soon 
reached. Recovery is said to occur in very rare instances. 

(Edema neonatorum, a subcutaneous oedema with induration, occur- 
ring in the new-born, commences in the legs and rapidly spreads until 
almost the whole body is affected. In rare cases it begins in the hands. 
There are marked drowsiness, great failure of vital power, and usually 
collapse ending in a short time in death. It is to be diagnosed by the 
lividity of the skin, the pitting of the parts on pressure, and the freedom 
of the joints from stiffness. 

40 



626 



DISEASES OF THE NERVOUS SYSTEM. 



ACROMEGALY. 

Definition. — A chronic disease characterized by enlargement of the 
hands, feet, and face. 

Etiology. — Acromegaly has been recorded as congenital, bnt usually 
it develops from the eighteenth to the twenty -fifth year, though it may 
come on at any time. No known causes can be assigned for it ; any 
influence of heredity is very obscure. 

Morbid Anatomy. — The nature of acromegaly is unknown. The en- 
largement of the bones is due to a true hypertrophy, which affects also the 
skin, the connective tissue, and the blood-vessels. In a number of cases 
the thyroid and the thymus gland have been found enlarged. The pitui- 
tary body also has been found hypertrophied 5 and Marie, who first de- 
scribed the disease, believes that the affection is a dystrophy, bearing the 
same relation to the pituitary body that niyxcedema bears to the thyroid 
gland. So many cases, however, of acromegaly without disease of the 
pituitary body, and so many cases of disease of the pituitary body without 
acromegaly, have been recorded, that the connection between the two is 
extremely problematic. 

Symptom atology. — The first change in acromegaly begins in the ends 
of the fingers and toes, the tip of the nose, the lips, and the chin. The 
swelling primarily affects the bony tissues, but soon invades all the tissues 
of the part, and finally spreads until it involves not only the whole face 
and the ankles and wrists, but also the clavicles, the sternum, the patellae, 
and even the vertebrae. The resulting appearance is very characteristic : 
the large feet and hands, the magnified face with its bones enormously 
thickened and lengthened, give an aspect that can scarcely be mistaken. 
The great toe and the ends of the fingers are apt to be especially out 
of proportion to the rest of the body ; the nails become broad and verti- 
cally grooved ; the lower jaw-bone may be so much affected as to project 
beyond the face, whilst the teeth are widely separated by the hyper- 
trophy of the alveolar processes. Very late in the disease kyphosis, due 
to enlargement of the vertebrae, is often present. 

Early in the disease some muscular feebleness, especially loss of en- 
durance, is apparent, although fine movements may be executed ; later 
awkwardness is a common symptom. A peculiar apathy, with sleepiness 
and dulness, is almost characteristic ; the headache may be so severe and 
persistent as to cause the patient to wish for death. Disturbances of 
vision, diabetes, and various other symptoms have been noticed, evidently 
the outcome of disturbances of the basal brain- centres. 

Diagnosis. — Acromegaly is distinguished from osteitis deformans of 
Paget by the facial rather than the cranial bones being attacked, and by 
the shafts of the long bones escaping. According to Marie, in Paget' s 
disease the face is triangular, with the base upward, whilst in acromeg- 
aly it is ovoid or egg-shaped, with the large end downward. Under the 



VASOMOTOR AND TROPHIC DISEASES. 



627 



name of pulmonary osteo- arthropathy Marie has reported a group of cases 
which resemble acromegaly, but which he considers to be separated from 
it by the facts that the disease is a complication of long-standing affections 
of the lungs, that the bones of the extremity, and especially their shafts, 
are early attacked, and that the phalanges are bulbous and enlarged, 
with curved nails, instead of being flattened as in acromegaly. 

Prognosis and Treatment. — Acromegaly may persist for many 
years without change, but seems never to undergo cure. No known 
treatment is of avail. 



SECTION nr. 
DISEASES OF THE CIRCULATORY APPARATUS. 



CHAPTEE I. 

DISEASES OF THE PERICARDIUM. 
PNEUMOPERICARDIUM. 

The presence of air or gas in the pericardial cavity is a rare con- 
dition. Air enters either through the perforation of a foreign body from 
the cutaneous surface, or from the oesophagus, or through the rupture of 
a pulmonary cavity. It may also enter in consequence of the advance of 
a cancer of the oesophagus, stomach, or intestine, or in the progress of a 
corrosive ulcer of the stomach. Gas may be formed in the pericardium 
from the admission of putrefactive bacteria. The presence of a con- 
siderable quantity of air or gas interferes with the action of the heart, 
resulting in dyspncea, cyanosis, collapse, and death ; lesser quantities 
rapidly cause inflammation. The area of cardiac dulness is replaced by 
a metallic tympany or cracked-pot sound, and a change in position causes 
tympany to be replaced by dulness. If fluid is likewise present, splash- 
ing may be heard. The valvular sounds have a metallic character, and 
are faint and often associated with a friction-sound. The physical signs 
thus resemble those of a circumscribed pneumothorax or large pulmo- 
nary cavity in the left chest near the heart. The dyspncea, however, is 
not of such rapid onset in these affections, while the audible metallic 
sounds persist when the breath is held, and percussion makes apparent 
the loss of cardiac dulness. The cardiac sounds may present a metallic 
character when the stomach is distended with air or gas, which also may 
cause palpitation and dyspncea. The recognition of the increased area 
of gastric tympany and the temporary nature of the disturbance are 
sufficient in the diagnosis. Although recovery from pneumopericardium 
sometimes occurs, the prognosis is generally grave, from the usual severity 
of the immediate causes. The treatment is that of a severe pericarditis, 
but is usually of no avail. 

H^EMOPERICARDIUM. 

Blood may be poured into the pericardial sac from injured vessels in 
the wall or from a traumatic perforation of the heart or the great vessels. 
628 



DISEASES OF THE PERICARDIUM. 



629 



The same result follows rupture of the heart, or of an aneurism of the 
adjacent portion of the aorta or of the coronary artery. The blood may 
enter the pericardium slowly, as in wounds or rupture of the heart, and 
the patient live for some days although a considerable quantity of blood 
accumulates, or it may enter rapidly from an aneurism. A small hemor- 
rhage produces temporary faintness, while slowly progressing hemorrhage 
causes pain in the region of the heart. Sudden profuse hemorrhage stops 
the action of the heart and occasions anaemia of the brain, associated with 
an increase in the area of cardiac dulness and a disappearance of the 
heart-sounds and the apex-beat. Haemopericardium, except in the case 
of wounds which are not severe, is almost of necessity fatal. 

The chief indication is for removal of the blood by the aspirator, a 
procedure which is said to have relieved the symptoms in some trau- 
matic cases. 

HYDROPERICARDIUM. 

The normal pericardium contains from one to several drachms of 
serous fluid. When several ounces, perhaps two or three pints, are 
present, the condition is known as hydropericardium, or pericardial 
dropsy. Although the fluid is usually serous in character, in rare in- 
stances it is milky from the presence of chyle. Such an excess of fluid is 
usually considered to be the result of general or local mechanical causes, 
of venous or lymphatic stagnation, or of disturbances of the nutrition of 
the walls of the blood-vessels. The general disturbances of circulation 
are to be found in disease of the valves of the heart or of the myocardium, 
and in obstruction to the passage of blood through the lung. The local 
obstructing causes are various thoracic tumors situated near the base 
of the heart. Disease of the kidney, cancer, tuberculosis, and profound 
anaemias are the possible sources of cachectic hydropericardium. 

A moderate quantity of fluid produces no symptoms ; large quantities 
interfere with the action of the heart and cause a sense of constriction, 
dyspnoea, and cyanosis. The physical signs indicative of the presence 
of fluid are an increase of dulness in the cardiac area, extending beyond 
the audible or palpable position of the apex, and enfeebled although 
otherwise unaltered heart- sounds. Hydropericardium is distinguished 
from serous pericarditis by the absence of the fever and friction -sounds 
indicative of an inflammatory process, and by the existence of general or 
local causes of dropsy, in which the pericardial effusion is usually of late 
occurrence. The increased area of dulness may suggest enlargement of 
the heart, but in cardiac hypertrophy the apex-beat is to be appreciated 
at the outer border of dulness, and is not intensified when the patient 
leans forward. The diagnosis may be especially difficult in dilatation of 
the right ventricle, which also increases the area of pericardial dulness, 
and aspiration may be necessary to determine the presence of free fluid. 
Since hydropericardium usually represents a late stage in the progress 
of incurable diseases, the prognosis is that of the basal disease, and is 



630 



DISEASES OF THE CIRCULATORY APPARATUS. 



unfavorable unless the cause can be removed. When the effusion is 
large, paracentesis may be practised. 

PERICARDITIS. 

Etiology. — Inflammation of the pericardium is usually regarded as 
due to an infection either from unknown sources or from recognized 
infectious processes. The former, the rarer variety, is called primary 
or idiopathic, while the latter is designated secondary pericarditis. It 
occurs in the course of a variety of diseases, in which the infectious 
agent is supposed to be transmitted to the pericardium by means of the 
blood-vessels. Among these are acute rheumatism, scarlet fever, variola, 
pneumonia, erysipelas, pyaemia and puerperal fever, and tuberculosis. 
These are all affections of which bacteria are regarded as the probable, 
if not the demonstrated, cause. Bacteria are also brought by means 
of the circulation from local lesions in more or less remote parts of the 
body, as from abscess or gangrene of the lungs, from visceral or periph- 
eral abscesses, from cutaneous erysipelas, or from infectious periostitis 
or osteomyelitis. The pericarditis occurring in scarlatina probably often 
arises from the transfer of bacteria from a complicating tonsillitis, while 
the virus of acute rheumatic pericarditis enters through unknown 
channels of invasion even before any articular inflammation is apparent. 
Pericarditis also arises from the extension of a bacterial inflammatory 
process from neighboring parts, whether following the course of a wound 
of the pericardium or proceeding from an abscess of the heart or from a 
pneumonic lung. Bacteria are also admitted from the peritoneal cavity 
through the diaphragm or from perforating abscesses of the liver. The 
inflammation of the pericardium may be an extension from a neighbor- 
ing cancer, as of the oesophagus or the stomach, from an aneurism of the 
aorta, from tubercular affections of the pleurae or peribronchial lymph- 
glands, and from carious ribs, sternum, or vertebrae. The occurrence 
of pericarditis as a complication of chronic nephritis and of scurvy is at- 
tributable to a toxaemia occurring in these affections, or to the favorable 
opportunities which these diseases furnish for the growth of bacteria in 
the pericardium. 

Pericarditis is more often found among males than among females, and 
is present at all periods of life, even in the foetus and in extreme old age. 

Morbid Anatomy. — According to the anatomical changes a distinc- 
tion is drawn between acute fibrinous, sero fibrinous, hemorrhagic, and 
purulent pericarditis, an acute or chronic tubercular pericarditis, and a 
chronic fibrous pericarditis. The anatomical appearances consist in the 
alterations of the pericardium, and in the variations in the characteristics 
of the exudation. Usually both parietal and visceral layers of the peri- 
cardium are diseased, although inflammatory changes may be limited 
to the one or the other layer. In acute pericarditis the pericardium is 
swollen, injected, and spots of punctate hemorrhage are to be seen. In 



DISEASES OF THE PERICARDIUM. 



631 



the earliest stage the surface is smooth, without lustre, but soon becomes 
roughened and opaque, and eventually covered to a greater or less extent 
with fibrinous false membrane, and the subjacent superficial layers of the 
myocardium may be of an opaque gray color. In acute tubercular 
pericarditis miliary tubercles, at times in enormous numbers, lie within 
the layers of the pericardium or slightly project from its surface. The 
exudation is composed of fibrin, serum, and cells, the last being both 
leukocytes and red blood-corpuscles. Bacteria are also frequently found, 
and comprise streptococci, staphylococci, and pneumococci, as well as the 
bacilli of tuberculosis, the colon bacillus, and, according to H. 0. Ernst, 
a variety of the bacillus pyocyaneus. 

According as one or the other of these constituents predominates is 
the anatomical variety of pericarditis designated. In fibrinous pericar- 
ditis there may be so little serum present that the term pericarditis sicca, 
or dry pericarditis, is applied. The fibrin may form a delicate, easily 
detached layer either adherent near the base of the heart or diffused 
over the greater part of the pericardial surface. Although at the outset 
the fibrinous exudation is confined to a limited surface, the incessant 
motion of the heart rapidly causes it to appear over constantly increasing 
areas. The fibrin may be present as a thick layer, the surface of which 
is irregularly ribbed and elevated, forming a tripe-like membrane from 
which papilliform masses project, producing the appearance known as 
villous heart, cor villosum. The fibrinous adhesions also may extend 
from one pericardial surface to the other, perhaps enclosing spaces in 
which more or less serum is confined. In serous, more properly sero- 
fibrinous, pericarditis the serum is constantly associated with fibrin, and 
the liquid exudation varies in quantity from several ounces to a quart or 
more. The serum is opaque from the presence of fibrinous flocculi, cells, 
and granular material, and gravitates towards the lowermost portions of 
the pericardial cavity unless confined by adhesions. In purulent peri- 
carditis the quantity of fibrin is less, the number of leukocytes greater, 
and considerable differences exist in individual cases in the proportion 
of pus-corpuscles to pus-serum. Usually a thin pus is present, and the 
quantity of fibrin is small. In hemorrhagic pericarditis the exudation, 
largely serous, contains red blood- corpuscles in greater or less number, 
but sufficient to produce a reddish discoloration of the liquid exudation, 
although usually not present so abundantly as to form blood-clots. A 
hemorrhagic exudation is commonly present in tubercular or cancerous 
pericarditis. In tubercular pericarditis there is a combination of mili- 
ary tubercles within the pericardium and a sero-fibrinous, purulent, or 
hemorrhagic exudation upon the surface. The tubercles may first become 
apparent after the fibrinous membrane is detached. In rare instances 
the bacilli of tuberculosis have been found in the purulent exudation of 
pericarditis although tubercles were absent, and have been regarded as 
the cause of the inflammation. In chronic tubercular pericarditis soft- 



632 



DISEASES OF THE CIRCULATORY APPARATUS. 



ened or calcified cheesy tubercles, inspissated exudation, and fibrous 
adhesions are combined. 

In chronic fibrous pericarditis the pericardium is opaque, thickened, 
and indurated. The resulting changes may be localized or diffused, are 
present as a so-called milk-spot or tendinous patch, or produce an ob- 
literation of the pericardial cavity from adhesions between the apposed 
surfaces. Chronic fibrous pericarditis is often the result of an acute 
pericarditis, the fibrous adhesions being replaced by fibrous bands. The 
fibrinous and cellular exudations are then disintegrated and encapsu- 
lated, and pockets filled with softened or calcified necrotic caseous 
material are seen between the parietal and the visceral pericardium. 
Mortar-like material or bone-like plates are to be found in the same 
region, and in extreme cases the heart may lie within a calcareous shell. 
The myocardium is usually in a condition of fatty degeneration or of 
brown atrophy, although the heart often is hypertrophied and dilated. 
In the severer varieties of acute pericarditis the inflammatory process 
may extend to the pleurae or to the mediastinal tissues, and an acute 
pleurisy or mediastinitis, perhaps suppurative in purulent pericarditis 
and indurative in chronic fibrous pericarditis, occurs. A suppurative 
pericarditis may result in perforation through the skin or into the pleural 
cavity or lung, more rarely into the oesophagus. 

Syaiptoms. — In the consideration of the symptoms of pericarditis a 
distinction is to be drawn between acute pericarditis and chronic peri- 
carditis, although at times the transition between the two is so gradual as 
not to be recognized. In acute pericarditis the symptoms may be so slight 
as to attract little or no attention, or there may be pain, perhaps aggra- 
vated on pressure, in the region of the heart, especially near the ensi- 
form cartilage. It is either continuous or occasional, and may radiate 
from the region of the heart into the neck or towards the left arm. With 
increasing exudation the pain becomes diminished and there is a sense of 
constriction often associated with palpitation. The pulse is usually feeble, 
rapid, and irregular, although it may be unexpectedly strong and not 
accelerated. The breathing becomes quickened, is perhaps difficult, and 
headache, dizziness, sensations of faintness, and a feeling of anxiety, some- 
times ending in despondency or delirium, may occur. During the farther 
progress of the disease there is usually moderate fever, the temperature 
generally not exceeding 102° F. In certain cases of pericarditis the onset 
is violent, being announced by a severe chill, and there is hyperpyrexia, 
the temperature rising to 107° or 108° F., especially towards the end of 
life. 

On physical examination at the beginning a sense of friction may be 
felt, but the sound of friction is to be heard either with the systole or with 
the diastole, sometimes with both, and in the latter case has a to-and-fro 
character not connected with the heart-sounds, and perhaps a gallop- 
rhythm. The friction-sound is furthermore characterized by inconstancy 



DISEASES OF THE PERICARDIUM. 



633 



and variability, now disappearing to return in the course of a few hours 
and perhaps showing an altered relation to the heart-beat. It is best 
heard in the immediate vicinity of the sternum, but may be confined to 
the base of the heart or to the apex, or be audible throughout the car- 
diac area. The sound is often superficial, being louder in the upright 
position of the patient, and may be increased on pressure of the stetho- 
scope. Although this sound is usually compared to the creaking of 
leather, it may have a blowing or musical character not differing from 
that of valvular murmurs, but is not connected with the valvular sounds, 
and generally presents the same intensity during systole and diastole. 
With the increase of the liquid exudation the intercostal spaces may 
be widened, and the region of the heart become abnormally prominent ; 
the sound of friction disappears, the cardiac sounds become faint, and 
the apex-beat is indistinct and is perhaps not to be felt. Epigastric 
pulsation is often observed, attributable to transmission of the aortic 
beat through the liver enlarged by passive congestion. The area of 
cardiac dulness is increased at first near the base of the heart, but later 
forms a triangle, the base of which may lie even below the sixth rib and 
extend between the nipples, while the apex is rounded and may lie in 
the vicinity of the second costal cartilage. The apex-beat is sometimes 
to be recognized when the body is bent forward, and then is found 
between the sternum and the limit of dulness on the left. As the exuda- 
tion increases, be it slowly or rapidly, the patient assumes a semiprone 
position, the expression is anxious, the breathing rapid, there is frequent 
cough, the skin is dusky, and the cervical veins are distended and pul- 
sating. The radial pulse is feeble and sometimes paradoxical, — that is, 
more frequent during inspiration than during expiration. The voice may 
be husky from pressure on the left recurrent laryngeal nerve, and swal- 
lowing be difficult from pressure on the oesophagus. The lower lobe of 
the left lung is retracted to make room for the pericardial effusion, and 
a dull tympanitic note is to be heard at the left of the area of car- 
diac dulness, where there are increased vocal resonance and bronchial 
breathing. In some cases these signs may be heard also below the angle 
of the left scapula, in consequence of compression of the lung. They 
diminish or disappear when the patient bends forward, especially if he 
can assume the knee-elbow position. 

The course of an acute pericarditis varies in accordance with the 
severity of the inflammatory process. In the milder cases, in which there 
is but little exudation, the discomfort ceases in the course of a few days 
and the temperature returns to the normal. In the more prolonged cases, 
in which there is abundant exudation, a favorable progress is indicated 
by a diminution of the area of dulness, which may occur rapidly, and a 
return of the friction-sound which had disappeared with the formation 
of the exudation. The presence of pus is to be suspected from repeated 
chills and wide variations in the course of the temperature. 



634 



DISEASES OF THE CIRCULATORY APPARATUS. 



Diagnosis. — The increased area of pericardial dulness may be dis- 
criminated with difficulty from that due to dilatation. The beat of the 
dilated heart is more readily recognized, and lies at the outermost border 
of dulness, not changing its situation with an alteration in the position of 
the patient. The heart- sounds are louder, and the evidence of retraction 
of the left lower lobe of the lung is lacking. Eotch attaches especial im- 
portance in the differential diagnosis to the absence of resonance in the 
fifth right intercostal space in pericardial exudation. The dulness from 
an encapsulated pleuritic exudation is to be excluded by the respiratory 
sounds and the vocal fremitus being enfeebled and not exaggerated as 
in pericardial effusion. The signs of pleuritic friction may be mistaken 
for those of a pericardial rub, and may be caused by the transmitted 
beating of the heart although the breath is held. The inconstancy, varia- 
bility, and wider diffusion of the pericardial sounds in the course of time 
enable the pleuritic friction to be excluded. A double friction-sound at 
the base of the heart may be mistaken for a double aortic murmur, but 
the latter is constant, is transmitted into the cervical arteries, and is 
associated with the characteristic water-hammer pulse and the systolic 
flushing of the capillaries. There are no means except aspiration by 
which the variations in the quality of the pericardial fluid can be abso- 
lutely determined. 

Prognosis. — The prognosis of acute pericarditis is usually favor- 
able, although this affection may end in obliteration of the pericar- 
dium. When there is abundant exudation death may occur in the 
course of a few days or within a fortnight, either from the pressure 
upon the heart of the exudation or from an associated degeneration of 
the muscular fibre. Usually when the exudation is fibrinous or sero- 
fibrinous, as in the pericarditis of acute rheumatism or of pneumonia, 
recovery takes place ; but when the exudation is purulent or hemor- 
rhagic the prognosis is grave, since purulent pericarditis is often the 
result of pyaemia and may precede death but a few days, while hemor- 
rhagic pericarditis is commonly caused by tuberculosis or cancer. Peri- 
carditis occurring in chronic nephritis or in an alcoholic patient is of 
grave prognosis. 

Treatment. — In the treatment of pericarditis it is essential that the 
patient be kept absolutely quiet in bed, with a total avoidance of any 
emotional or physical excitement which should increase the activity of 
the heart. In rare cases, when the patient is robust, from two to eight 
ounces of blood may be taken by leeches or cups, to be followed by a 
local application of cold by means of ice-bags or Leiter's tubes. If the 
heart's action be excessive and the pulse strong, aconite may be given 
in drop doses at varying intervals according to effect. It is essential to 
watch carefully the action of this drug, lest its influence be overexerted ; 
and when in the advancing periods of the disease cardiac embarrassment 
occurs, aconite is capable of doing great harm ; at such stages digitalis 



DISEASES OF THE PERICARDIUM. 



635 



may be employed. What is said of the action of digitalis in myocarditis 
(page 647) is true also in pericarditis. 

The appearance of a pericarditis in a rheumatic attack should usually 
be the signal for at least the temporary increase of the anti-rheumatic 
remedies, and in robust persons, when the effusion is serous and exces- 
teive, the old pill of calomel, digitalis, and squill, one grain each, may 
be tried. 

When there is much pain, anxiety, restlessness, or insomnia, opium 
should be given in sufficient doses to control the symptoms. Sulphonal 
is probably a harmless hypnotic, though uncertain ; trional may be 
given cautiously 5 chloral must be avoided. In the advanced stages of 
pericarditis, especially when there is much exudation, blisters should 
be used. 

Paracentesis of the pericardium is indicated when the heart is embar- * 
rassed by a large serous exudation. Uncertainty as to the nature of the 
exudation often interferes greatly with the selection of suitable cases for 
the operation ; but, as the operation is not a serious one, it may be used 
in all doubtful cases. Our own experience with it in rheumatic pericar- 
ditis has been that it has done neither good nor harm. In a collection of 
sixty cases of pericarditis of various character made by Eoberts there 
were twenty-four recoveries after paracentesis. A small needle should 
be thrust directly backward in the fifth intercostal space, two inches to 
the left of the left edge of the sternum, so as to avoid the internal mam- 
mary artery. When the effusion is very large, some authorities prefer 
introducing the needle close to the costal margin in the left costo-xiphoid 
angle and pushing it upward and backward. Eotch asserts that aspira- 
tion should be practised at the fifth interspace to the right of the 
sternum. The fluid should be drawn slowly ; if it prove to be purulent, 
an incision may be made, or even a resection of the rib ; cautious irri- 
gation of the pericardial sac sometimes works well, but is not free from 
danger, and is usually unnecessary. 

Cardiac weakness in the advanced stages of pericarditis must be met 
by the use of digitalis and strophanthus, and occasionally by more rap- 
idly acting diffusive stimulants, such as alcohol, camphor, or Hoffmann's 
anodyne. 

Chronic Pericarditis. — Chronic pericarditis is either chronic from 
the outset or more frequently represents the persistence of an acute peri- 
carditis, during the occurrence of which it is impossible to determine 
whether or not a chronic pericarditis is to result. Although an acute 
fibrinous or sero- fibrinous pericarditis may pursue a chronic course, tuber- 
cular pericarditis is the variety almost sure to become chronic in case the 
patient lives. In the chronic pericarditis which represents the outcome 
of an acute attack, the fever disappears, perhaps to return temporarily 
for short intervals, but the area of cardiac dulness remains enlarged, 
although gradually diminishing, and the result is an obliteration of the 



636 



DISEASES OF THE CIRCULATORY APPARATUS. 



pericardium. The symptoms and signs of an obliterative pericarditis are 
therefore those of a chronic fibrous pericarditis. The anatomical changes 
have already been mentioned, and the nature of the degeneration of the 
myocardium stated. The symptoms are attributable to this degenera- 
tion, and consist in the evidences of a weakened myocardium, — namely, 
palpitation, dyspnoea, perhaps a sense of constriction in the region of the 
heart, and eventually cyanosis and dropsy. These general symptoms are 
slowly progressive and are aggravated by motion. The weakness of the 
heart is also indicated by a feeble apex-beat and pulse. The symptoms 
associated with chronic fibrous pericarditis are therefore not character- 
istic, and this lesion is generally discovered after death, having been 
unsuspected during life. The increased area of cardiac dulness is due 
to the enlargement of the heart, which is usually both hypertrophied 
and dilated. The sign to which especial importance is attached is a 
systolic retraction of the apex, frequently associated with which is a 
collapse of the cervical veins during diastole. According to Eiess, the 
heart- sounds have a metallic character in obliteration of the pericardial 
sac when the stomach is dilated and tympanitic. 

The treatment in chronic pericarditis consists of rest, avoidance of 
excitement, and the use of cardiac stimulants or sedatives pro re nata. 
In some cases repeated blistering is of service. When the pericardium is 
adherent, all that can be done is to meet symptoms as they arise. 



DISEASES OF THE HEART AND MYOCARDIUM. 



637 



CHAPTEE II. 

DISEASES OF THE HEART AND MYOCARDIUM. 
MALFORMATION. 

Malformations of the heart are due either to arrest of development 
or to foetal endocarditis or to both. When not inconsistent with life they 
are productive of a series of disturbances sometimes continued into adult 
age. The most important of these malformations are certain defects in 
the formation of the septa between the auricles and ventricles. An open 
foramen ovale is of frequent occurrence, but is of such slight clinical im- 
portance as to attract but little attention even when large, since, owing 
to the presence of the Eustachian valve, it seldom gives rise to symptoms. 
In rare instances there is little or no interauricular septum, and the heart 
practically contains but one auricle and two ventricles, and is then called 
a trilocular biventricular heart. More common is a defective formation 
of the interventricular septum, which when slight is manifested by an 
opening at the upper part of the septum beneath an aortic crescent. In 
some cases there is no septum, and the heart containing three cavities is 
called a trilocular biauricular heart. In the most extreme instances both 
the auricular and the ventricular septa are lacking and a bilocular heart 
is present. 

The most common malformation is a stenosis of the pulmonary ori- 
fice, either from a muscular thickening of the conus arteriosus or from 
a foetal endocarditis of the pulmonary valves. The presence of the latter 
causation is to be admitted only when sclerosis or vegetations are present 
and the rest of the heart is normal. Frequently the pulmonary stenosis 
is associated with a patent foramen ovale, a perforate ventricular septum, 
a persistent ductus arteriosus, and hypertrophy of the right ventricle. 

Stenosis of the aortic orifice is rare. More common is an excess in 
the number of crescents, which may be four or five. Thickening and 
deformity of the tricuspid valve are occasionally to be found in the absence 
of other lesions of the heart, and are suggestive of a foetal endocarditis. 
A foetal endocarditis of the mitral valve is also possible, though generally 
considered as of rare occurrence. The frequent presence of abnormal 
tendinous threads, especially stretched across the left ventricle, although 
a congenital malformation, is of no symptomatic importance. 

Symptoms. — Malformation of the heart may produce no symptoms, 
the lesion being discovered after death. On the other hand, disturbance 
of circulation may become apparent soon after birth, usually increasing 
with the growth of the individual, and may be continued into adult life, 
even into old age. The symptoms often lessen with the growth of the 



638 



DISEASES OF THE CIRCULATORY APPARATUS. 



individual, either from compensatory hypertrophy or from the more fre- 
quent avoidance in the adult of the exciting causes of undue activity 
of the heart. The most common symptom of congenital heart disease 
is cyanosis, a bluish discoloration of the skin, especially of the face and 
extremities, which is increased on exertion. This symptom may be 
associated with dyspnoea and cough, perhaps with dizziness and faintness. 
The skin is frequently cool, and the fingers and toes are clubbed. The 
cyanosis is regarded by some as a passive congestion of the cutaneous 
vessels, and by others as the result of an admixture of arterial and 
venous blood through an open foramen ovale, or of a defective aeration 
of the blood in consequence of narrowing of the pulmonary orifice. 

Diagnosis. — The diagnosis of congenital heart disease is based upon 
the occurrence of the above-mentioned symptoms, especially of cyanosis 
and the presence of a murmur. The nature of the malformation is rarely 
to be recognized by characteristic signs. An open foramen ovale causes 
no abnormal heart- sounds. A perforate ventricular septum is likely to 
cause hypertrophy of the right ventricle from overwork, and may pro- 
duce a systolic murmur at the base of the heart, accompanied by a thrill, 
which is not continued into the aorta. Stenosis of the pulmonary orifice 
is indicated by a single or double murmur in the region of the pulmonary 
valve. A persistent ductus arteriosus also causes hypertrophy of the 
right ventricle, a systolic murmur, and a palpable thrill in the region of 
the pulmonic orifice ; but the frequent association of these lesions makes 
it impossible to explain the physical signs by one or another malforma- 
tion, since any one or all may produce the same result. The rare steno- 
sis of the descending portion of the arch of the aorta, which is associ- 
ated with an open ductus arteriosus, is manifested by hypertrophy of 
the left ventricle, dilatation of the arch of the aorta, and the visible en- 
largement of the anastomoses between the branches of the epigastric 
and internal mammary arteries. According to Hochsinger, loud cardiac 
murmurs heard in children are of probable congenital origin, whether 
with or without increase of dulness of the right side of the heart. They 
are also suggestive of a congenital origin if heard in the pulmonary area 
without accentuation of the second pulmonic sound. The presence of 
a palpable thrill suggests an open ductus arteriosus or a perforate septum. 

ATROPHY. 

The heart may be abnormally small as the result of a symmetrical 
arrest of development (aplasia or hypoplasia). Such a heart is usually 
associated with a thin, narrow, and elastic aorta, with small arteries, and 
sometimes with irregularities in the development of the genitals. The 
significance of this condition in chlorosis has already been mentioned. 
(See page 5.) 

Atrophy of the heart, the result of acquired conditions, is to be 
found in elderly persons and in emaciated patients suffering from chronic 



DISEASES OF THE HEART AND MYOCARDIUM. 



639 



wasting diseases, as cancer and tuberculosis : hence senile and marantic 
atrophies are to be recognized. The heart may also become atrophied in 
consequence of the long- continued pressure of abundant exudation or 
from chronic adhesive pericarditis. The heart is diminished in size, the 
pericardium wrinkled, the subpericardial fat greatly diminished in quan- 
tity, gelatinous and saffron- colored, while the muscular substance is of 
increased consistency and of a reddish -brown color from the presence of 
numerous pigment-granules in the vicinity of the nuclei. The atrophied 
heart is weak, but produces no characteristic disturbances. 

Treatment. — There is no special treatment of cardiac malformations 
or of cardiac atrophy. The general therapeutic principles of chronic 
heart disease are to be applied to the individual case. (See page 668. ) 

HYPERTROPHY. 

Hypertrophy of the heart is divided into simple hypertrophy, in 
which there is no dilatation of the cavities, and eccentric hypertrophy, in 
which dilatation of the cavities and hypertrophy of the wall are com- 
bined. A distinction is further drawn between primary or idiopathic 
hypertrophy, in which anatomical causes are not readily appreciated, and 
secondary hypertrophy, in which mechanical obstructions to the circula- 
tion are easily recognized. 

Etiology. — The immediate cause of cardiac hypertrophy is an in- 
creased demand for the work of the heart, but that hypertrophy shall 
result it is essential that the patient be well nourished. A demand for 
increased work is produced by obstruction to the circulation either in the 
general arterial system, in the lungs, or in the heart itself. Obstruction 
in the general arterial system may be caused by aortic hypoplasia, aneu- 
rism, or arterio-sclerosis. The pulmonary circulation is obstructed in 
emphysema, in fibrous pneumonia, and, by compression of the lung, in 
chronic pleurisy or curvature of the spine. Valvular disease and obliter- 
ative pericarditis are cardiac causes of obstruction. Hypertrophy may 
also be produced by excessive action of the heart in the absence of any 
obstruction to the circulation. Such excessive action may be due to the 
occupation of the individual, and be either continuous or the result 
of temporary but extreme strain. It may likewise be occasioned by dis- 
turbance of the nervous system in consequence of mental excitement, or 
of the conditions occurring in Graves's disease. The hypertrophy is 
furthermore attributable to the effect of certain poisons upon the nervous 
system, as tea, coffee, tobacco, and alcohol. The hypertrophied heart in 
chronic interstitial nephritis is usually regarded as the result of increased 
tension of the arterioles dependent upon defective elimination of waste 
through the kidneys, and lesser degrees of hypertrophy are to be found 
in acute nephritis. The frequency of cardiac hypertrophy in consequence 
of excessive beer- drinking is a well- recognized fact. 

Morbid Anatomy. — The hypertrophied heart is increased both in size 



640 



DISEASES OF THE CIRCULATORY APPARATUS. 



and in weight, the latter being of more value than the former as evidence 
of hypertrophy, since enlargement of the heart also results from dila- 
tation of the cavities, in which case the thickness of the wall may be even 
less than normal. The weight of the normal heart is from eight to ten 
ounces, while the hypertrophied heart may weigh in the vicinity of three 
pounds, and the wall, which is red and resistant, may be three times as 
thick as normal. The papillae and trabecule usually are enlarged, and 
the papillae of the mitral valve may be nearly of the size of the thumb. 
The appearances of the hypertrophied heart vary somewhat according 
to the cause. If the obstruction is at the aortic orifice or in the general 
arterial system, the left ventricle becomes conspicuously enlarged and 
the heart elongated. If the obstruction is in the pulmonary circula- 
tion, the right ventricle is particularly hypertrophied and the heart is 
widened. When both ventricles are hypertrophied, dilatation is usually 
associated, and the heart, both elongated and widened, attains an enor- 
mous size, and is compared to that of cattle, cor bovinum. 

Symptoms. — Hypertrophy of the heart, if just sufficient to overcome 
the obstructing cause, produces but little disturbance. The patient may 
have a sense of fulness in the head, of ringing in the ears, or of weight 
in the epigastrium, and may complain of powerful beating of the heart. 
A tendency to nasal hemorrhage is not infrequent, and it is in such cases 
that the possibility of cerebral hemorrhage should be held in mind. 
The pulse is full, strong, and resistant, the apex-beat is visible and pal- 
pable over an abnormally large area, and pulsation of the carotids is 
unusually vigorous. The first sound of the heart is dull and prolonged, 
and the second sound at the base is accentuated. The accentuation is of 
the aortic second sound in predominant hypertrophy of the left ventricle, 
and of the pulmonic sound when the right ventricle is conspicuously 
hypertrophied. In the latter case the patient is more likely to complain 
of short breath, and the impulse, perhaps exaggerated, of the heart is to 
be recognized near the ensiform cartilage, but the radial pulse lacks the 
characteristics above mentioned. The area of cardiac dulness is elongated 
downward and outward from hypertrophy of the left ventricle, and in 
extreme cases of hypertrophy with dilatation may reach as far to the left 
as the nipple-line and below the sixth interspace. If the hypertrophy 
affects chiefly the right ventricle, the area of cardiac dulness is extended 
to the right beyond the edge of the sternum, and the increased area of 
cardiac dulness to the left of the sternum is chiefly due to the displace- 
ment caused by the enlarged right ventricle. In extreme cases of hyper- 
trophy and dilatation the precordial region is distended, and the beat of 
the heart is to be recognized over a wide area. 

Diagnosis. — The diagnosis of hypertrophy of the heart is easily made 
from the persistent powerful beat of the heart, the character of the pulse, 
and the accentuation of the second sounds at the base. 

Prognosis. — Since hypertrophy of the heart is to be regarded as a 



DISEASES OF THE HEART AND MYOCARDIUM. 



641 



means of compensating for pathological conditions, its presence is to be 
regarded as fortunate. Its occurrence, therefore, is favorable while the 
nutrition of the body can be maintained and the amount of work done 
is in proportion to the strength of the individual. Insufficient nour- 
ishment or overwork and the persistence or aggravation of the exciting 
causes rapidly or gradually induce a failing compensation, the prognosis 
of which is uncertain. 

Treatment. — See Treatment of Chronic Heart Disease, page 668. 

DILATATION. 

Dilatation of the heart is the result of weakness of the cardiac muscle. 
This weakness may be caused by a sudden, prolonged, or extreme strain, 
or it may be due to a degeneration of the myocardium occasioned by in- 
fectious diseases, by such poisons as arsenic and phosphorus, or by dis- 
ease of the myocardium resulting from affections of the coronary vessels 
or from the extension of a pericarditis. The most frequent cause of dila- 
tation of the heart is the failure of the hypertrophied myocardium to 
overcome the resistance which has been offered, this failure being the 
result of the persistence, perhaps of the progressive nature, of the causes, 
and the lack of sufficient rest and nutrition. 

Morbid Anatomy. — Simple dilatation of the heart is characterized 
by an increase in the size of the cavities and by a thinning of the walls. 
The heart is therefore enlarged, although the weight is not increased, 
unless, as is often the case, hypertrophy is associated, in which event the 
wall of the heart may be of normal or increased thickness. Since dilata- 
tion is often the result of degenerative changes in the myocardium, the 
consistency of the muscle is either diminished, the color being of a red- 
dish gray or yellow when granular or fatty degeneration is present, or 
the density is increased and the muscle in considerable part replaced by 
fibrous tissue in the case of fibrous myocarditis. When hypertrophy is 
combined with dilatation, the latter being conspicuous, the papilla are 
flattened and the endocardium is thickened and opaque, especially in the 
ventricle exposed to the greatest strain. 

Symptoms. — The symptoms of a dilated heart are essentially those of 
cardiac insufficiency, either gradually progressing from bad to worse or 
preceded by evidence of hypertrophy in case the dilatation is secondary 
to hypertrophy. Palpitation, pain referred to the region of the heart, 
dyspnoea, bronchial catarrh, perhaps pulmonary hemorrhage, vertigo, 
faintness, and wakefulness, partly in consequence of the tumultuous beat- 
ing of the heart, are the immediate results of dilatation of the left ven- 
tricle. The pulse is soft, frequent, and irregular. The heart-sounds are 
sharper, though fainter than in the earlier stages of hypertrophy, and 
reduplication of the first sound is frequently to be heard. Eventually 
symptoms of insufficiency of the right ventricle predominate, and there 
is obstruction to the passage of blood through the lungs, which is shown 

41 



642 



DISEASES OF THE CIRCULATORY APPARATUS. 



by increased dyspnoea and frequent cough. Obstruction to the peripheral 
venous system follows, and is made evident by dropsy, enlargement of 
the liver, gastro-intestinal catarrh, and a concentrated albuminous urine. 

Diagnosis. — The diagnosis of dilatation of the heart depends upon 
the association of increased cardiac dulness, feeble impulse, and gallop - 
rhythm. JSTo considerable alteration of the area of cardiac dulness takes 
place unless dilatation is associated with hypertrophy. In case of dilata- 
tion and hypertrophy of the left ventricle, if the dilatation predominates 
the apex-beat is less vigorous and the accentuation of the aortic second 
sound is less pronounced than when hypertrophy is the more conspicuous. 
If dilatation of the right ventricle predominates over hypertrophy the 
physical signs are less in evidence than are the symptoms, although ac- 
centuation of the second pulmonic sound is less conspicuous than when 
hypertrophy exists. The increased area of dulness may be simulated by 
an encapsulated pleurisy in the immediate vicinity of the heart, but in 
this affection, while the area of dulness may change, the heart-sounds are 
not modified on alteration of the position, and the apex-beat is independent 
of the outer line of dulness. An increased area of dulness may also result 
from tumor or excessive fat in the mediastinum. In such cases there is 
likely to be no modification of the pulse, the heart-sounds, or the position 
of the apex. 

Prognosis. — If the causes of dilatation of the heart are temporary, 
recovery may take place 5 if permanent, relief is afforded only by the 
occurrence of hypertrophy, which demands diminished work or increased 
nutrition, or both. The prognosis in the individual case, therefore, is 
determined largely by the results of treatment, and is in general the more 
favorable the younger the patient. 

Treatment. — See Treatment of Chronic Heart Disease, page 668. 

FATTY INFILTRATION. 

Fatty infiltration of the heart is indicated by an increased accumula- 
tion of fat in the subpericardial, interstitial, and subendocardial fibrous 
tissue. These structures represent one of the physiological reservoirs 
of fat, and store this material under conditions which favor its accumu- 
lation in the other fat -reservoirs of the body : hence fatty infiltration 
of the heart is found in obese persons in whom, from an inherited ten- 
dency, sedentary habits, or an excessive fat-forming diet, or from a com- 
bination of these factors, fat is more rapidly absorbed than consumed. 
The degree of fatty infiltration varies extremely : the more abundant the 
subpericardial infiltration the more does the fat spread over the heart, 
following the distribution of the coronary vessels, and the more likely are 
the intermuscular tissue and the subendocardial tissue to become infil- 
trated. The muscular bundles may be separated by the fat, and in ex- 
treme cases atrophy of the muscular fibres occurs, although considerable 
degrees of fatty infiltration may exist without degenerative changes in 



DISEASES OF THE HEART AND MYOCARDIUM. 



643 



the muscle. It is even possible that hypertrophy and dilatation of the 
heart may be combined with fatty infiltration. 

Symptoms. — Fatty infiltration of the heart to a considerable degree 
may exist without the production of symptoms ; but, especially when 7 as 
happens in the majority of cases, it is combined with excessive general 
obesity, it may cause marked shortness of breath upon exertion, though 
the muscle-fibre has not undergone degeneration. Any extra work, 
mental or physical, thrown upon such a heart, or depression from inter- 
current acute disease, may bring sharp manifestations of a weak heart, 
such as palpitation, precordial distress, rapid breathing, vertigo, faint- 
ness, or cyanosis. With associated degeneration of the muscular fibre 
of the heart these attacks become more frequent, and are combined with 
those of fatty degeneration. 

There are no characteristic signs of fatty infiltration, and the increased 
area of cardiac dulness is so slight as to be recognized with difficulty. 
The apex-beat is feeble, the valvular sounds are faint, and the pulse has 
no constant character, although it is usually regular and of moderate ten- 
sion. The diagnosis is therefore based upon the occurrence of the symp- 
toms of a weak heart in a fat person. Since excessive fat may be removed 
from other fat -reservoirs under appropriate treatment, the same result 
may occur in the heart, and the distressing symptoms of fatty infiltration 
may disappear with the loss of weight, not to return, provided a reaccu- 
mulation of fat does not take place. On the contrary, persistent fatty 
infiltration of the heart may prove a source of danger, as well as of dis- 
comfort, by favoring fatty degeneration of the muscular fibre, with its 
possibilities of sudden death from paralysis of the heart under even com- 
paratively slight provocation. 

Treatment. — The treatment of fatty infiltration of the heart is that 
of obesity. (See page 59. ) With the reduction of the general corpulence 
improvement of the heart almost invariably takes place. When the car- 
diac symptoms are very severe, care is required, especially in the begin- 
ning of the treatment, to graduate the exercise. In these cases the plan 
of hill-climbing, as instituted by Oertl, is especially useful. A mountain- 
path is marked at regular distances, and the patient is required each day 
to walk so many yards farther than the day before, the amount of work 
done being steadily increased until it becomes very large. There is no 
reason for supposing that this form of exercise is superior to other forms, 
except in the certainty with which the amount of work can be regulated. 
Graduated exercise is of the greatest service in all cases of fatty infiltra- 
tion, and should be carefully tried even when there is reason to fear that 
there have been some changes in the heart-fibres. 

fatty degeneration. 

Fatty degeneration of the heart is considered to be due mainly to 
impairment of nutrition or defective oxidation. Local causes may exist, 



644 



DISEASES OE THE CIRCULATORY APPARATUS. 



as sclerosis of the coronary arteries, fibrous myocarditis, chronic peri- 
carditis, and the conditions producing hypertrophy. General causes are 
also important, as poisoning by phosphorus, arsenic, and alcohol, and 
by the toxins of certain acute infectious diseases, especially diphtheria. 
Fatty degeneration of the heart occurs also from the impoverishment of 
the blood in profound or pernicious anaemia, and in cachexia, particularly 
that arising from cancer or pulmonary tuberculosis. 

The entire heart may present a homogeneous opaque grayish- yellow 
color, with or without opaque yellow spots seated in the papillary muscles 
or in the wall of the heart, which between them is of a red color. The 
more extensive the distribution of the fatty changes the more diminished 
is the resistance of the flabby heart. If local causes of fatty degeneration 
exist, the appearances of fatty degeneration are to be found in the regions 
conspicuously affected, whether in one side of the heart, in a cavity, or in 
a portion of the wall. 

The symptoms of fatty degeneration are those of cardiac insufficiency 
or weakness, and are usually indicative of a predominance of the fatty 
degeneration in the left half of the heart. At times the function of the 
right half of the heart is conspicuously affected, or, when the causes are 
general, the signs of weakness of both ventricles are present. Palpitation, 
rapid breathing, cardiac pain, perhaps attacks of angina, and a soft, 
irregular pulse of small volume, feeble heart- sounds, often reduplication 
of the first sound at the apex, occur in fatty degeneration of the left 
ventricle. There are also dizziness, faintness, ringing in the ears, and 
Cheyne- Stokes breathing. Fatty degeneration of the right side of the 
heart causes catarrhal conditions, dropsy, and cyanosis, although these 
effects are not often observed except when the fatty degeneration occurs 
in the sequence of hypertrophy and dilatation. 

The diagnosis of fatty degeneration of the heart is based upon the 
occurrence of symptoms of cardiac weakness not relieved by treatment in 
connection with the above-mentioned causes. Arcus senilis and resistant 
or calcified radial arteries are not evidences of fatty degeneration of the 
heart. 

The prognosis is always grave, since the lesion represents a terminal 
stage in the processes or conditions producing it. When fatty degenera- 
tion is circumscribed the fat may be absorbed and a scar remain. Ex- 
tensive fatty degeneration results in death either suddenly from cardiac 
paralysis or more gradually from oedema of the lungs. 

Treatment. — The treatment of fatty degeneration of the heart is in 
great part that of cardiac dilatation. (See page 670.) The method of 
Oertl (see page 643), which yields such good results in fatty infiltration, 
is very dangerous in fatty degeneration, and, if practised at all, should 
be restricted to the milder forms of the disease. For evident reasons, 
when profound structural change has occurred in the heart-muscle, digi- 
talis and other drugs which act upon the muscle -fibres are almost or 



DISEASES OF THE HEART AND MYOCARDIUM. 



645 



altogether powerless. Under such circumstances absolute rest affords the 
only relief for the patient. * 

MYOCARDITIS. 

The occurrence of anatomical changes in the myocardium under vari- 
ous conditions has long been known, but the associated symptoms do not 
differ materially from those attributable to a weak heart from fatty infil- 
tration or fatty degeneration. Of late years a special place in nosology 
is often assigned to myocarditis, and a primary or idiopathic variety is 
distinguished from the secondary variety occurring in the course of endo- 
carditis or pericarditis. A further distinction of importance is that be- 
tween acute and chronic myocarditis. 

Etiology. — The most important cause of acute myocarditis is to be 
found in infectious diseases, and its symptoms may be expected in the 
course of diphtheria, scarlet fever, typhoid fever, small-pox, septicaemia, 
pyaemia, erysipelas, puerperal fever, influenza, and gonorrhoea. Chronic 
myocarditis occurs at any age, though usually after middle life, and is of 
especial frequency from excess in food and alcohol, from physical strain, 
and from arterio-sclerosis however caused. A chronic infectious myo- 
carditis results from the invasion of the myocardium by the bacilli of 
tuberculosis, by the virus of syphilis, and by actinomyces. The lesions 
occurring in actinomycosis are so rare as not to require particular notice, 
while those present in tuberculosis and syphilis are especially mentioned 
in the general consideration of those subjects. 

Morbid Anatomy. — The anatomical changes are found both in the 
muscle- cells and in the fibrous tissue : hence a parenchymatous myocar- 
ditis is distinguished from an interstitial myocarditis, it being always 
acute, while interstitial myocarditis may be either acute or chronic. The 
latter distinction is one of convenience, since parenchymatous changes 
probably precede the development of fibrous tissue. 

In acute parenchymatous myocarditis the muscle is opaque gray and 
brittle, the muscle- cells are in a state of granular, fatty, or hyaline de- 
generation, and the muscular fibres are frequently separated. This last 
condition is known as disassociation or fragmentation, and has been re- 
garded as an important pathological state. It occurs under a variety of 
circumstances, not only in acute but also in chronic myocarditis, in sudden 
death from violence, in death from shock after operations, and in diseases 
of the brain. It is now generally considered that the fragmentation of 
the fibres takes place from irregular and powerful contractions of the 
heart during the death-agony. The characteristic appearances of acute 
interstitial myocarditis are to be found as minute opaque gray or yellow 
spots with a red margin, the miliary abscesses, which sometimes become 
confluent, and are readily seen beneath the pericardium and the endo- 
cardium. A dark red or reddish-yellow, soft, and friable portion of the 
heart-wall, generally in the vicinity of acutely diseased valves, is also in- 
dicative of an acute interstitial myocarditis, and represents the result of 



646 



DISEASES OF THE CIRCULATORY APPARATUS. 



the extension of a septic inflammation from the valve to the heart-wall, 
being at times dne to the Motion of a valvular vegetation or thrombus. 

Chronic myocarditis is manifested in the earlier stages by the pres- 
ence of opaque white or yellow spots and patches, best seen on section of 
the wall of the left ventricle and of the interventricular septum. At a 
later period they are soft and depressed below the surface, the condition 
to which Ziegler has applied the term myomalacia. After the softened 
material has been absorbed, fibrous scars remain, which weaken the ven- 
tricular wall and favor a dilatation of the cavity. A portion of the ven- 
tricular wall may thus be transformed into a fibrous plate which serves 
as a source of aneurism of the heart, but sometimes becomes calcified 
and forms an unyielding plate. 

SY3IPT03IS. — The symptoms of myocarditis are those indicative of a 
weak heart, — namely, palpitation, precordial discomfort, sometimes an- 
gina pectoris, vertigo, faintness, rapid breathing on slight exertion, dis- 
turbance of digestion, and cyanosis, perhaps eventually dropsy. The 
grouping and severity of these symptoms vary. In acute myocarditis, 
for instance, the rapid, often irregular and weak pulse and palpitation 
by some are regarded as due to the alterations of the myocardium, by 
others are considered as evidences of a disturbance of cardiac innervation. 
Such symptoms may occur and no lesions be found after death, or the 
typical lesions of acute myocarditis may be found in the absence of such 
symptoms. On the other hand, the severer symptoms so often present in 
chronic myocarditis are to be found in other lesions of the heart, and the 
anatomical changes of chronic myocarditis may occur even in persons 
dying suddenly yet without antecedent symptoms calling attention to 
disease of the heart. In general, the symptoms of chronic myocarditis 
are those of progressive weakening of the heart, of slow development, but 
suddenly becoming serious, if not fatal, under physical or mental excite- 
ment. The auscultatory signs attributable to an acute myocarditis are 
merely weakness and rapidity of the heart-sounds. In chronic endocar- 
ditis there is likely to be an increased area of cardiac dulness, especially to 
the left, and the apex- beat is feeble, but visible over a somewhat widened 
area. The heart-sounds are also feeble, especially the second aortic sound, 
while there is a tendency to reduplication of the first sound at the apex. 
Murmurs are absent unless the valves eventually become incompetent. 
The pulse is irregular, soft, and of small volume, usually quickened under 
slight nervous or physical excitement, though sometimes slow, and does 
not materially change in character under treatment. 

Dia&xosis. — The diagnosis is based upon the association of symp- 
toms of a weak heart with a rapid, irregular, feeble pulse independent of 
valvular disease and unaffected by treatment, and upon the progressive 
nature of the symptoms. The distinction between an acute and a chronic 
myocarditis depends upon the occurrence of the symptoms of a weak 
heart as the result of an infectious disease in a person previously well. 



DISEASES OF THE HEART AND MYOCARDIUM. 



647 



The discrimination between an acnte interstitial and an acute parenchy- 
matous myocarditis is not to be absolutely made, since a parenchymatous 
affection is always associated with the interstitial process. In favor of 
an acute interstitial myocarditis is the occurrence of chills in malignant 
endocarditis or in a septic thrombophlebitis, especially when evidences of 
minute arterial embolism are to be found in the skin or the retina. The 
diagnosis of acute parenchymatous myocarditis is safely to be made when 
the symptoms of a weakened heart are present in acute infectious diseases 
in which evidences of a localized suppurative or necrotic process likely 
to cause bacterial embolism are lacking. The symptoms of chronic myo- 
carditis may be confounded with those of a cardiac neurosis, but their per 
sistence, their independence of emotional excitement and of the abuse 
of tea, coffee, and alcohol, and the absence of digestive and pelvic dis- 
turbances, are important in differentiation. Although the symptoms 
resemble those of a fatty heart, fatty infiltration of the heart is ex- 
cluded by the absence of excessive obesity. The distinction between 
fatty degeneration of the heart and chronic myocarditis is based upon 
the difference in etiology and upon the more protracted course of chronic 
myocarditis. A dilated and hypertrophied heart also presents similar 
symptoms, but the dilated hypertrophied heart is essentially in a con- 
dition of chronic myocarditis. The distinction, therefore, is based upon 
the etiology, the antecedent symptdms of hypertrophy, the presence of 
an increased area of dulness, and especially, for a time at least, the bene- 
ficial results of treatment. 

Prognosis. — The prognosis of acute myocarditis is essentially that of 
the disease in which the myocarditis occurs. It is therefore favorable in 
some cases, although sudden death from cardiac paralysis or rupture may 
occur. It is to be remembered, however, that the eventual progressive 
occurrence of symptoms of chronic myocarditis may be the result of a 
previous acute infectious disease. It is obviously impossible to determine 
the extent and degree of the acute myocarditis in acute infectious diseases 
terminating in recovery. Chronic myocarditis may exist for years, but is 
a progressive affection. Compensatory hypertrophy may last for a while, 
but eventually, as in valvular disease, cardiac insufficiency arises, either 
rapidly or slowly, with its final fatal result. 

Treatment. — In the treatment of acute myocarditis it is essential to 
prescribe absolute rest, physical and mental, with a careful use, if there 
be evidences of heart-failure, of digitalis and strophanthus. We have no 
definite knowledge, however, of the influence of these remedies upon an 
acutely degenerating heart-tissue ; but we do know that when the cardiac 
process is severe the heart will not respond functionally either to digi- 
talis or to strophanthus. It is evident, therefore, that the exhibition of 
large doses of cardiac stimulants in acute myocarditis is of very doubtful 
expediency, and that the attempt to force the heart to respond to these 
remedies is hazardous. 



648 



DISEASES OF THE CTECUEATORY APPARATUS. 



In chronic myocarditis we have no control over the process of de- 
generation, and the treatment must be limited to the application of the 
principles of chronic cardiac therapensis. (See page 668 ; also Fatty 
Degeneration, page 644.) 

THROMBOSIS. 

Thrombi are of frequent occurrence in the heart as a result either of 
alteration of the surface or of obstruction to the circulation, hence are to 
be found in acute and chronic endocarditis, and in hearts enfeebled either 
by wasting diseases or by chronic myocarditis. Thrombi are present on 
the valves and in the recesses of the heart, especially in the auricular 
appendages and between the ventricular trabecular. They are often con- 
founded with post-mortem clots, but are to be discriminated by their ad- 
herence (not entanglement among the trabecular), their brittleness, their 
lack of lustre, and their color, which is more gray or reddish gray than red. 
In shape they are more globular or flattened than elongated. Since they 
occur in an enfeebled heart, the symptoms of cardiac weakness are asso- 
ciated. There is no reason to suppose that the thrombi are a cause of 
the weakness, although formerly the cardiac polypus was regarded as a 
frequent cause of digestive as well as circulatory disturbances, and the 
condition was often erroneously diagnosticated. Cardiac thrombi are to 
be regarded as complications of the general and local diseases in which 
they occur, and not infrequently prove fatal by becoming the source of 
emboli, which may produce sudden death by obstructing the pulmonary 
or the coronary artery or a valvular orifice in the heart. In rare in- 
stances the effect of their presence is beneficial, as when they obliterate 
the cavity of a cardiac aneurism. 

Treatment. — There is no known means of affecting cardiac emboli 
or thrombi ; the treatment of cardiac thrombosis is therefore that of acute 
myocarditis or myocardial degeneration which follows the arrest of cir- 
culation : in coronary embolism the treatment is that of angina pectoris. 
When a large area of the heart is involved, no remedies are of any avail, 
save for the relief of pain. (See Angina Pectoris, page 684. ) 

ANEURISM OF THE HEART. 

Localized dilatation of the ventricular wall weakened in chronic fibrous 
myocarditis is a condition which has been designated aneurism, or partial 
aneurism, of the heart. A distinction is to be drawn between this, the 
usual variety, and acute cardiac aneurism, which is the result of an acute 
interstitial myocarditis extended from an acute valvular endocarditis, 
and, according to Ponfick, caused by the friction of a diseased valve 
upon the heart-wall. As the destruction of the wall advances from within, 
a cavity is formed in the myocardium, often sinuous, and eventually, per- 
haps, leading to perforation. The chronic dilatation is most frequently 
found at the apex of the left ventricle, although sometimes observed in 
the interventricular septum, in which case the aneurism protrudes into 



DISEASES OF THE HEART AND MYOCARDIUM. 



649 



the right ventricle in consequence of the greater pressure of the left ven- 
tricle against its contents. The aneurism varies in size, and either is a 
localized bulging of the outer surface of the ventricle or appears as a 
sac nearly as large as the fist. It is usually single, although sometimes 
two are present. In the latter case there may be one or two openings 
between the heart and the aneurismal sac. The wall of the aneurism 
is composed of pericardium and endocardium with the remains of the 
myocardium, and the opening between the ventricular cavity and the in- 
terior of the aneurism is either round or elongated, large or small. The 
larger aneurisms contain lamellated thrombi, which may almost entirely 
fill the cavity. The pericardial cavity is usually obliterated, and the wall 
of the aneurism may be calcified. At first sight the larger cardiac aneu- 
risms suggest simply an hypertrophied heart, and the symptoms present 
during life are merely those of a weakened heart the beat of which is 
to be seen over an abnormally wide area, although the radial pulse is 
strong in comparison with the weak impulse of the apparently enlarged 
heart. Death usually results from progressive cardiac insufficiency, 
although sometimes from rupture of the aneurism into the pericardium 
or the lungs. The diagnosis is generally made after death. No treatment 
is of service. 

RUPTURE. 

Eupture of the heart results both from violence and from disease 
of the myocardium. Traumatic rupture is the result of penetrating 
wounds of the heart, or of violence applied to the surface of the body 
without producing evidence of any considerable external injury. In the 
latter case a sharply defined tear through the wall of the heart, especially 
of the auricle, takes place, there being but little hemorrhagic infiltration 
and no evidence of degeneration in the vicinity. 

Spontaneous rupture occurs as the result of a previously diseased 
heart, oftenest in myomalacia from obstruction of the coronary arteries or 
from fatty degeneration, more rarely from the friction of a diseased valve 
during acute endocarditis or from the extension of an abscess to the sur- 
face of the heart. Eupture also occurs from the bursting of an aneurism 
of the heart, and in rare instances from tumors in the wall or from a 
thinning of the wall, or in consequence of the advance of a gastric ulcer 
through the intervening diaphragm and pericardium. The usual seat of 
spontaneous rupture is near the apex of the left ventricle, but the ven- 
tricular septum is sometimes perforated. The tear, often closed by a clot, 
is generally zigzag, the inner and outer openings not being on the same 
level. The walls of the rent are infiltrated with blood, and the limiting 
muscular fibre is either necrotic or in a condition of fatty degeneration. 
The pericardium contains more or less clotted blood. The symptoms 
due to the rupture generally follow those attributable to stenosis of the 
coronary arteries, chronic myocarditis, or fatty degeneration of the heart. 
The perforation through the pericardium is frequently preceded, perhaps 



650 DISEASES OF THE CIRCULATORY APPARATUS. 

for several days, by attacks of precordial pain, a sense of oppression, 
and faintness or dyspnoea. Finally, perhaps after slight exertion, there 
are sudden intense pain referred to the heart, great anxiety, rapid res- 
piration, absent pulse, perhaps cyanosis, followed by convulsions and 
death. The immediately fatal issue depends upon the compression of 
the heart by the abundant hemorrhage into the pericardial sac, which 
produces an increase in the area of cardiac dulness. Treatment of this 
condition is obviously of no avail. 

TUMORS. 

Primary tumors of the heart, as fibroma, myxoma, lipoma, and sar- 
coma, are rare. Of especial pathological interest is the congenital myo- 
sarcoma, with its striated muscle-cells. Secondary tumors, as cancer or 
sarcoma, may grow into the heart from adjacent structures, or may be 
therein localized in consequence of disease in remote parts. Single or 
multiple nodules may be present and result in extensive deformity of 
the heart. Since they produce no characteristic symptoms and demand 
no specific treatment, the interest in them is more pathological than 
clinical. 



DISEASES OF THE ENDOCARDIUM. 



651 



CHAPTEE III. 

DISEASES OF THE ENDOCARDIUM. 
ENDOCARDITIS. 

Inflammation of the endocardium is to be regarded rather as a con- 
dition occurring in a variety of diseases and from numerous causes than 
as a sharply denned disease. All endocarditis is, therefore, to be con- 
sidered as secondary, although clinically a primary endocarditis is of 
necessity admitted when satisfactory evidence of an antecedent disease 
is lacking. Usually the valvular endocardium is especially involved, 
but the inflammatory process may be limited to various parts of the 
parietal endocardium, especially to the trabecule and apices of the 
papillae, while in many instances both the valvular and the parietal en- 
docardium may be simultaneously diseased. In general, when the term 
endocarditis is used valvular endocarditis is the variety meant. Since, 
however, the clinical characteristics and perhaps the etiology of chronic 
endocarditis differ widely from those of acute endocarditis, the first dis- 
tinction of practical importance to be drawn is that between acute and 
chronic endocarditis. 

acute endocarditis. 

Etiology. — It has long been assumed that inflammation of the endo- 
cardium is the result of an irritant brought by the blood, this irritant 
being supposed to exist in certain diseases from the frequent occurrence 
of endocarditis as a complication of such diseases. Importance in the 
etiology of endocarditis, therefore, has been assigned to acute articular 
rheumatism, chorea, influenza, diphtheria, pneumonia, scarlet fever, 
measles, variola, typhoid fever, relapsing fever, the infectious wound dis- 
eases, erysipelas, osteomyelitis and periostitis, pyaemia, septicaemia, puer- 
peral infections, dysentery, malaria, tuberculosis, cancer, diabetes, and 
nephritis. Of late years attention has been directed to the occurrence of 
endocarditis as well as myocarditis in gonorrhoea. The discovery of the 
frequent presence of bacteria within and upon the diseased endocardium 
in infectious diseases has led to the prevailing view of the bacterial origin 
of endocarditis : hence the occurrence of an apparently primary inflam- 
mation of the endocardium is usually explained by the assumption of an 
infection from a suppurative process anywhere in the body, perhaps con- 
cealed or manifested by an apparently insignificant superficial abscess. 
The occurrence of endocarditis as a complication of ulceration of the ali- 
mentary canal or of an ulcerating cancer is also thus explained. Bacteria 
are found with great frequency in certain cases of endocarditis, although 
they have not been found in all. Among those found are the streptococ- 



652 



DISEASES OF THE CIRCULATORY APPARATUS. 



cus, staphylococcus, diplococcus pneumoniae, gonococcus, the bacillus of 
tuberculosis, the bacillus of diphtheria, and the typhoid bacillus. They 
may be present in abundance or so few in number that they are discov- 
ered only by the results of cultivation. When found they are to be con- 
sidered as important in the etiology of the process, Orth having demon- 
strated that when bacteria alone were introduced into the circulation 
endocarditis did not follow, but if at the same time the valves were 
injured an infectious endocarditis arose, although injury alone was not 
equally efficient. All acute endocarditis, however, has not been proved 
to be bacterial, and since several varieties of bacteria are to be found in 
bacterial endocarditis, and this affection occurs in a variety of diseases, 
a ready explanation is offered for the otherwise perplexing variation in 
the symptoms, course, duration, and results of endocarditis. 

A mixed bacterial infection is important in the etiology of endocar- 
ditis, since well-known micro-organisms are found in the affected valves 
in diseases whose specific bacterial origin is inferred but as yet not 
demonstrated. Local causes are also important, since bacteria may be 
present in the blood and no endocarditis result, and endocarditis is only 
an occasional complication of the various diseases in which it may occur. 
For example, endocarditis is more often seated in that side of the heart 
which works the harder. It is, therefore, more commonly found in the 
right side of the heart in the foetus, and in the left side of the heart 
after birth. The lesions also are first to be found upon those portions 
of the valve which are exposed to the greatest friction. Its frequent 
occurrence in early life, especially in children, is attributable to a feeble 
resistance to bacterial action in youth. It is stated that a bacterial 
endocarditis may also result, although rarely, from embolism of the 
nutrient arteries of the valves, especially of the cuspid valves. Non- 
bacterial forms of endocarditis are designated as simple endocarditis, in 
contradistinction to bacterial or mycotic endocarditis. A clinical dis- 
tinction is drawn between simple and septic or malignant endocarditis 
from the variations in the character of the symptoms, progress, and 
results. Abundant bacteria are present in septic endocarditis, whereas 
they are often to be found with difficulty, if at all, in simple endocar- 
ditis. The distinction, however, is one of degree in the severity of the 
endocarditis, and is not based upon absolute etiological differences. 

Morbid Anatomy. — At the outset of acute endocarditis there are 
slight swelling and opacity of the endocardium, which soon becomes 
further modified by the formation of granulation-tissue within the valve. 
These early changes are to be found along the line of apposition. As the 
inflammation progresses, granular or warty excrescences project from 
the surface, when the term warty or verrucous endocarditis is applied. 
The vegetations or outgrowths are covered with granular and fibrillated 
material composed of leukocytes, blood-plates, and fibrin, essentially a 
thrombus, or the thrombus may first be formed, being subsequently in- 



DISEASES OF THE ENDOCARDIUM. 



653 



vaded by the granulations. The thrombi may attain a considerable size, 
and bacteria are sometimes present, but with far less frequency than in 
the ulcerative variety of endocarditis. These alterations, limited at the 
outset, involve in the course of time more and more of the valve, and may 
extend to the tendons and adjacent portions of the parietal endocardium. 

Acute endocarditis may also progress with extensive destruction of 
the valve, and is then designated diphtheritic, acute ulcerative, septic, or 
malignant endocarditis, according as the anatomical changes or the clini- 
cal characteristics are made prominent. The alterations at the outset re- 
semble those occurring in verrucous endocarditis, but the valve rapidly 
becomes thickened and opaque and of diminished consistency. Superficial 
loss of substance early occurs, and thrombi of considerable size are formed 
upon the valve. Both the thickened valve and the thrombi usually con- 
tain bacteria in enormous numbers, and the inflammatory process rapidly 
extends to the valve-tendons and to the parietal endocardium, especially 
where this is exposed to the friction of a diseased valve. In conse- 
quence of the diminished resistance of the valve, the weakest portion of 
the crescents or cusps often yields to the pressure of the blood, and a 
localized diverticulum, perhaps of the size of a pea, the acute valvular 
aneurism, arises, which not infrequently becomes perforated. Some of 
the softened tendons of the mitral valve may be torn apart. As pre- 
viously stated, the so-called acute aneurism of the heart is the result of 
the beating of the diseased valve against the myocardium, which is 
invaded by bacteria and undergoes an acute necrosis. Acute ulcerative 
endocarditis is therefore regarded as a secondary condition occurring in 
the course of septic infection, and the localization in the valvular endo- 
cardium of the infectious bacteria is favored by previous disease of the 
valves. 

Embolism may occur both in simple or verrucous endocarditis and in 
the septic or acute ulcerative variety. In the former the emboli are car- 
ried to the spleen, kidneys, brain, and extremities, and are usually pro- 
ductive of mechanical disturbances alone. In malignant endocarditis the 
emboli, being small but septic, are less productive of mechanical than of 
inflammatory disturbance. The numerous minute emboli are often trans- 
ferred to various parts of the body, and give rise to miliary abscesses 
either in the heart or in the spleen, kidneys, liver, stomach, and intes- 
tine, brain, or eye. Miliary embolism also occurs in the joints and skin. 

Symptoms. — The symptoms of acute endocarditis vary within wide 
limits. In the simple form, which is usually of the warty variety, there 
may be no symptoms indicative of this lesion. On the other hand, the 
evidence of an endocarditis may first be furnished by the symptoms of 
embolism, as sudden hemiplegia, renal pain, and hematuria, or pain in 
the region of the spleen in case of arterial embolism, or dyspnoea, hemop- 
tysis, cough, and pleuritic pain in pulmonary embolism. Since simple 
endocarditis is of most frequent occurrence as a complication of acute 



654 



DISEASES OF THE CIRCULATORY APPARATUS. 



rheumatism, in this affection repeated examinations of the heart should 
be made with reference to the discovery of abnormal physical condi- 
tions in this organ. Attention may first be directed to the heart by 
the occurrence of palpitation, a sense of precordial oppression, or per- 
haps dyspnoea, or there may be a sudden increase in the fever without 
any modification in the course of the articular inflammation. On the 
other hand, there may be no especial alteration in the range of the tem- 
perature or pulse. 

The appearance of a murmur over one of the valves is no necessary 
indication of an endocarditis, since the murmur may be functional or 
haemic, and endocarditis often occurs without any murmur being recog- 
nized. The distinction between a murmur caused by organic disease of 
the valves or of the orifice and a murmur independent of such lesions 
is not always to be easily made. The cardio respiratory murmurs, repre- 
sented by a jerking inspiration synchronous with the beat of the heart, are 
readily eliminated, since they are limited to inspiration and cease when 
the breath is held. An endocardial murmur is to be differentiated from 
an exocardial murmur by its usual association with the systole or diastole, 
its greatest intensity near a valve, its deep seat, and its failure to become 
increased by pressure of the stethoscope or by a change to the upright 
position. The functional murmurs occur in relative insufficiency of the 
valves, in which dilatation of the orifice prevents closure by the cusps or 
crescents 5 and also in functional insufficiency, in which in consequence 
of fatty degeneration of the papillary muscles the cusps are not held in 
place. They are present also in anaemia and in convalescence from febrile 
diseases. A systolic murmur at the base is likely to be functional if 
limited to the left of the sternum and unaccompanied by a thrill ; if at 
the right of the sternum, it is likely to be functional provided it occurs in 
a healthy person or in one not suffering from signs and symptoms of 
aortic stenosis. A systolic murmur at the apex in persons free from 
symptoms of cardiac incompetency may be functional or organic, and its 
actual nature is to be determined only in the course of time by the dis- 
appearance of the functional and the persistence of the organic murmur. 
Organic murmurs vary in intensity, pitch, and character, and when sys- 
tolic are frequently associated with disappearance of the first or second 
sound, according to the seat of the murmur. Functional murmurs are 
generally soft and occur during the systole, although an organic murmur 
may be soft and systolic ; but with functional murmurs the heart-sounds 
are unaffected. 

Endocarditis is designated septic or malignant when symptoms of 
septicaemia are present and are associated with conspicuous evidence of 
a diseased endocardium. In infectious diseases the occurrence of ma- 
lignant endocarditis is often manifested merely by an aggravation of the 
septic symptoms. Malignant endocarditis usually follows one of two types, 
the typhoid or the pyaemic. In the typhoid type there is a continued 



DISEASES OF THE ENDOCARDIUM. 



655 



atypical fever with considerable variations in the morning and evening 
temperature, a rapid pulse of diminished tension and volume, marked 
prostration, headache, perhaps delirium, and muscular pains. The skin 
is often dusky, sometimes jaundiced, petechia or rose-spots are not in- 
frequently present, and there may be profuse sweating. The abdomen 
is often moderately distended and tympanitic, and enlargement of the 
spleen is frequent. The tongue is dry, and diarrhoea is often present. 
The urine is high-colored and faintly albuminous. Although the physi- 
cal examination of the heart may disclose a mitral or an aortic murmur, 
this is not necessarily present. The area of cardiac dulness is usually 
slightly enlarged. If the physical examination of the heart is negative, 
the symptoms are essentially those of a septicemia of obscure origin. 
In the pysemic type of malignant endocarditis there is less mental and 
physical prostration at the outset than in the typhoid variety, and 
the temperature is intermittent, with extreme variations in the daily 
range. The exacerbations are often associated with chills, and the fall 
of the temperature is accompanied by profuse sweating. The chills are 
usually irregular, though sometimes of such periodicity as to suggest 
intermittent fever, and in the intervals between them the patient may 
be comparatively comfortable. There is progressive though gradual loss 
of flesh and strength. This variety may be prolonged over a period 
of months, Osier having reported a case continued over a period of ten 
months with daily intermittent pyrexia, the height of the temperature 
varying from 102.5° to 104° F., occasionally preceded by chills, oftener 
by chilliness. In this variety the symptoms of embolism are of fre- 
quent occurrence, manifested in the skin by a petechial or a papular 
eruption, in the intestine by diarrhoea especially of a hemorrhagic char- 
acter ; by symptoms of acute meningitis, perhaps by hemiplegia, when 
the brain is affected, and by pain in the region of the spleen, hsema- 
turia, or signs of acute hemorrhagic nephritis, in the case of involve- 
ment of the spleen and kidneys. The physical examination of the 
heart is negative, or murmurs are to be heard attributable to disturb- 
ance of function, or the signs are those of a localized valvular disease. 
The last event is of constant occurrence when the malignant endocar- 
ditis is a recurrent attack. 

The course of acute endocarditis varies extremely in accordance with 
the etiology, the previous condition of the patient, and the various com- 
plications. Although cases of simple or verrucous endocarditis generally 
recover from the immediate symptoms, chronic valvular endocarditis is 
the usual outcome. Malignant endocarditis may prove fatal within a 
few days, or, as in typhoid fever, within a few weeks, or, as in chronic 
pyaemia, the course may extend over a period of months. Simple endo- 
carditis may suddenly assume a malignant type. The embolic disturb- 
ances in simple endocarditis may be severe in virtue of the large size 
of the emboli and the situation of the organ obstructed. The embolism 



656 



DISEASES OF THE CIRCULATORY APPARATUS. 



of malignant endocarditis is more serious, although the emboli are usu- 
ally smaller. Their number and infectious qualities are the chief causes 
of their danger, since the suppurative inflammation of serous membranes 
is likely to result from their frequent presence near the surface of organs. 

Diagnosis. — Since the physical examination of the heart may give no 
evidence of a localized lesion, the diagnosis of acute endocarditis is often 
made only at a post-mortem examination. In the diseases in which endo- 
carditis occurs as a complication, attention may be directed to the heart 
by palpitation, precordial discomfort, and dyspnoea out of proportion to 
the febrile condition present. If a murmur is heard its significance is 
to be determined by the characteristics stated. The existence of the 
endocarditis may first be made apparent by the recognition of the symp- 
toms of embolism of the general arterial system. The probable simple or 
septic course of the endocarditis often may be inferred from the etiology 
even before the characteristic septic or pyemic symptoms arise. The 
endocarditis complicating acute rheumatism, chorea, small- pox, typhoid 
fever and diphtheria, scarlet fever and debilitating diseases, is likely 
to be of a simple character, while the endocarditis present in traumatic, 
puerperal, and gonococcal infections is often of a malignant type. The 
endocarditis occurring in pneumonia is generally simple, but may be 
malignant. A considerable enlargement of the spleen and cutaneous 
and retinal hemorrhages are evidences of the malignant nature of the 
endocarditis. Since the symptoms of malignant endocarditis are those 
of a toxaemia, either a septicaemia or a septico-pyaemia, and the course 
of malignant endocarditis may resemble that of typhoid fever, malarial 
fever, or acute tuberculosis, it frequently becomes necessary to exclude 
these diseases. The onset of typhoid fever is usually more gradual, the 
range of temperature is more typical, and functional disturbance of the 
heart is not a conspicuous feature. Malarial fevers are to be excluded 
by the examination of the blood or by the inutility of quinine. In acute 
general tuberculosis the onset is more gradual, there is often evidence of 
a localized tuberculosis, and the predominant signs are those of pulmonic 
disease. 

Prognosis. — The prognosis of simple acute endocarditis is generally 
favorable as to the immediate outcome, although eventually serious, since 
this disease is usually productive of an incurable valvular deformity, and 
it is also to be remembered that grave results from embolism may occur. 
Furthermore, the prognosis is to be guarded, since simple endocarditis 
quickly may become septic. The prognosis of malignant endocarditis, 
although extremely grave, is not absolutely hopeless. The immediate 
attack, if recovered from, leaves behind a permanently damaged heart. 

Treatment. — In the great majority of cases endocarditis is due to an 
infection which can be little modified by treatment. If, however, it is pos- 
sible to affect the cause of the endocarditis, no time should be lost in so 
doing. Thus, an antitoxin may be used in diphtheria ; or, if the case be 



DISEASES OF THE ENDOCARDIUM. 



657 



of rheumatic origin, ammonium salicylate should be given for the first 
forty-eight hours in sufficient doses to produce pronounced cinchonism. 
Subsequently great caution is necessary in the use of the salicylates, on 
account of their markedly depressing influence. In some cases of sthenic 
endocarditis in the earlier days of the disease calomel should be exhibited. 

When the endocarditis is fully developed, the treatment must be 
symptomatic. If there be sthenic cardiac excitement, aconite should be 
employed ; when, as is usually the case, the tendency is to cardiac weak- 
ness, it is a very dangerous remedy. Digitalis is to be used even in the 
earlier stages of the disease when there is great cardiac embarrassment 
with irregular heart -action ; but in cases which are not septic digitalis 
is not often required until the later stages of the disease, when the symp- 
toms of cardiac failure become threatening or the acute endocarditis is 
passing into valvular disease and it is important to favor compensatory 
hypertrophy. When heart-failure is imminent, diffusible stimulants, 
such as alcohol, ether, and camphor, may be used : strychnine is im- 
portant. For the control of -pain morphine may be given hypodermi- 
cally. It is better to repeat small doses, at short intervals if necessary, 
than to exhibit large single amounts. 

Local treatment is of little, if any, avail. If the application of ice, or 
of Leiter's tubes with cold or with hot water, be grateful to the patient, 
it may be resorted to. Mustard plasters are to be employed in crises 
of suffering and distress. It is very doubtful whether blisters have any 
influence upon the disease, and they may add greatly to the suffering 
of the patient. 

During the whole course of an endocarditis absolute quiet should 
be insisted upon, with most careful nursing to prevent exertion or ex- 
haustion. The patient should not be allowed to get out of bed for any 
purpose. The food should be light and nutritious. 

CHRONIC ENDOCARDITIS. 

Etiology. — Chronic endocarditis commonly results from the per- 
sistent and progressive character of the tissue-changes arising in acute 
endocarditis, especially in the verrucous variety, since malignant endo- 
carditis is so often fatal. In the rare cases of recovery from malignant 
endocarditis permanent alteration of the endocardium also results : hence 
the etiology of chronic endocarditis is largely that of acute endocarditis, 
the majority of the cases being the result of acute articular rheumatism. 
In addition, importance is to be attached to syphilis, gout, alcohol, and 
lead, and also to the complex and indefinite disturbances occurring in 
advancing years, among which may be included the effects of extreme or 
prolonged strain of the heart. 

Morbid Anatomy. — A parietal and a valvular form of chronic 
endocarditis occur, but the latter alone is of especial clinical importance. 
Two anatomical varieties of chronic valvular endocarditis are to be recog- 

42 



658 



DISEASES OF THE CIRCULATORY APPARATUS. 



nized, the one a fibrous endocarditis, the other a chronic ulcerative endo- 
carditis. Fibrous endocarditis is manifested by thickening, induration, 
adhesion, and contraction of the valve crescents or cusps. The valves thus 
become shortened, and the septa between adjacent crescents may be so 
diminished that two of the crescents are apparently fused into one, and 
the cusps of the auriculo- ventricular valves may be unified by adhesions. 
In addition, lime salts may be deposited in the deformed valves, in conse- 
quence of which they become rigid. The calcification takes place through- 
out the valve or at limited portions at the free edge or in the region of 
attachment, and the lime salts may also be deposited in thrombi attached 
to the surface of the valve. As a result, the valves may have a mulberry- 
like or jagged surface, the valve- tendons may become thickened, indu- 
rated, adherent, and shortened, and the insertion of the mitral valve, in 
which such changes are frequent, may be represented by a calcareous ring. 
In chronic ulcerative endocarditis, necrosis and fatty degeneration take 
place in the thickened valve, and the disintegrated portions are washed 
away in the blood- current, leaving more or less extensive loss of sub- 
stance, the atheromatous ulcers. 

Chronic valvular endocarditis of congenital origin affects the right 
side of the heart, especially the tricuspid valve. Acquired endocarditis 
is usually limited to the left side of the heart, although in rare instances 
the right side may be affected. The mitral valve is oftenest diseased, 
and next in frequency is inflammation of the aortic valve. The tri- 
cuspid valve is occasionally the seat, but the pulmonary valve is rarely 
inflamed. The aortic and mitral valves may be simultaneously affected, 
and the mitral and tricuspid likewise. In rare cases the aortic, mitral, 
and tricuspid valves are diseased, while in extremely rare instances all 
the four valves are inflamed. Disease limited to the mitral valve is 
more frequent in early life, while late in life the aortic valve is oftener 
diseased, largely owing to the frequency of chronic endaortitis after fifty 
years of age. 

The effect upon the heart depends upon the duration, degree, and 
result of the valvular affection, and is manifested by dilatation of the 
cavities and hypertrophy of the wall, the one or the other predominating 
according to the nature of the functional disturbance of the valve : these 
alterations are found in one cavity or in one side of the heart according 
to the valve conspicuously altered. In extreme cases of hypertrophy 
the weight of the heart may be increased threefold or fourfold, and the 
thickness of the ventricular wall may be three or four times the normal. 
Papillae and trabecule are enlarged, and the myocardium is increased in 
density and of a dark-red color, becoming grayish-red as compensation 
fails. The endocardium, particularly of the cavity longest exposed to 
the effects of the valvular disease, becomes thickened, and the wall of 
the dilated auricle, especially of the left auricle in mitral stenosis, may 
be largely fibrous. 



DISEASES OF THE ENDOCARDIUM. 



659 



Symptoms. — The symptoms of chronic endocarditis are those of 
chronic valvular disease of the heart, and are of gradual development in 
consequence of the progressive nature of the valvular deformity and the 
simultaneous compensatory hypertrophy of the wall of the heart. The 
existence of a chronic endocarditis is often recognized on physical exam- 
ination before any symptoms arise, or is discovered when cardiac symp- 
toms appear in the course of an acute recurrent endocarditis. 

The effect of the thickening, contraction, calcification, or perforation 
of the valves is such deformity as to interfere with their function or to 
produce an obstruction at the orifices which they guard. Either the 
valves become incompetent to close the orifice, and hence permit a re- 
gurgitation of the column of blood, or a narrowing of the orifice is 
occasioned, causing obstruction to the passage of blood. The incompe- 
tence of the valves to close the orifice is usually designated insufficiency, 
while obstruction to the passage of blood through the orifice is indi- 
cated by the term stenosis. Often the alterations of the valves are such 
that the orifice is narrowed and the valves are unable to close the open- 
ing, hence incompetence and stenosis coexist. A distinction is drawn 
between organic, relative, and functional insufficiency of the valve. In 
the first the inability to close the orifice is the result of anatomical 
changes in the valves or at the orifice. In relative insufficiency the 
normal valves are unable to close the orifice, owing to its dilatation 
with the dilatation of the heart, whereas in functional insufficiency 
the papillary muscles are so weakened, usually in consequence of fatty 
or fibrous degeneration, as to be unable to hold the valve-curtains in 
place. 

The immediate effect of incompetence of the valves or of stenosis of 
the orifice is an overfilling of the auricle or the ventricle, which is able 
to empty itself only by increased work. If the valves are insufficient, the 
ventricle or the auricle, according as the crescentic or the cuspid valves 
are affected, becomes distended not only by the blood which normally 
enters in sufficient quantity to fill it, but also by the return of blood 
already expelled which leaks through the incompetent valves. In steno- 
sis additional work is demanded of the heart to force through a nar- 
rowed opening the normal quantity of blood contained by the cavity. 
This additional work is accomplished by means of an increase of the 
heart- muscle, to which the term compensatory hypertrophy is applied. 
That such hypertrophy may take place it is necessary that the digestion 
be relatively normal, that sufficient and suitable nourishment be had, 
and that the various functions of the body be in good working order. 
Since the valvular lesions tend to produce increased deformity in the 
course of time, the hypertrophy also progresses, and as long as it is suf- 
ficient little or no disturbance to the comfort of the individual results. 
If, however, digestion fails, or food is defective in quality or quantity, or 
repeated unusual demands are made upon the heart, the muscular fibre 



660 



DISEASES OF THE CIRCULATORY APPARATUS. 



degenerates, and the cavities of the heart become incompetent to expel 
their contents. Since a normal quantity of blood then cannot be forced 
through the left side of the heart, it accumulates in the pulmonary veins 
and capillaries, thereby producing an increased resistance to the passage 
of blood through the right ventricle into the pulmonary artery. The 
inability of the right ventricle to empty itself causes an accumulation of 
blood in the right auricle and also in the general venous system. The 
ultimate effect, therefore, of all valvular disease of the heart is failing 
compensation and venous congestion throughout the body. 

The laboring heart then beats appreciably and sometimes tumultu- 
ously, the bronchial mucous membrane becomes swollen from the conges- 
tion of its blood-vessels, and the distended pulmonary capillaries project 
into the alveoli, which are thus prevented from receiving the necessary 
quantity of air, and rapid and short breathing results, indicative of the 
attempt to aerate the increased quantity of blood in the lungs. This 
cardiac dyspnoea is therefore chiefly due to mechanical causes inter- 
fering with the normal rapidity of the flow of blood through the lungs 
and with the admission of air for its oxygenation. It is therefore of 
earlier and more constant occurrence in mitral disease than in affec- 
tions of other valves. Both inspiration and expiration are impeded, 
and the frequency of respiration is accelerated. As the mechanical dif- 
ficulties increase in consequence of the progressive weakening of the 
compensatory hypertrophy, the difficulty of breathing becomes more 
apparent, and is constant, instead of being occasional and produced only 
by obvious causes. 

The dyspnoea is not infrequently manifested in the form of cardiac 
asthma, which occurs more frequently in aortic than in mitral disease, and 
occurs in fibrous myocarditis or in simple dilatation of the left ventricle. 
The attacks are occasioned by some obvious exciting cause, as unusual 
physical exercise, mental or moral disturbance, an attack of indiges- 
tion, prolonged exposure to cold, or may occur without any appreciable 
exciting cause. The patient is not infrequently aroused from sleep by a 
sense of substernal constriction, and the asthmatic attack rapidly pro- 
gresses, anxiety, orthopnoea, cyanosis, sweating, and coldness of the skin 
being present. The pulse is quickened and of diminished tension. Often 
moist rales are to be heard in the posterior and lower portions of the 
lungs, and dry rales are present elsewhere. There is usually little or no 
expectoration, although in extreme cases acute oedema may occur and 
a bloody frothy fluid be raised. The paroxysm may last an hour or 
more, gradually lessening in severity until it fades away. The attacks 
recur frequently or after long periods of intervening freedom from dis- 
turbance, according to the cause and the effects of treatment. 

The especial variety of dyspnoea to which the term Cheyne-Stolces 
breathing is applied occurs also in the failing compensation of cardiac 
disease, especially in aortic affections, fibrous myocarditis, and fatty de- 



DISEASES OF THE ENDOCARDIUM. 



661 



generation. In this variety of dyspnoea the patient ceases to breathe 
for an interval of fifteen to thirty or more seconds, when the breathing 
begins, becoming rapidly and progressively quickened for an interval of 
several seconds, after which the respirations are fewer and longer and 
finally cease, the inspirations being resumed at intervals of a minute, 
more or less. During the period of arrested breathing the pulse is rapid 
and weak, but becomes slower and stronger with the beginning of respira- 
tion. Cheyne-Stokes breathing occurs during sleep or when the patient 
is awake, and is continuous or paroxysmal. Its occurrence is usually 
indicative of a late stage in failing compensation, although we have 
known it to be continued at intervals for a period of two years. It is 
frequently relieved by appropriate treatment. 

The difficulty of respiration is added to in the course of time by a 
transudation of serum from the blood-vessels, which accumulates in the 
alveoli and bronchi, thus further interfering with the admission of air. 
The alveolar epithelium is desquamated, red blood- corpuscles pass 
through the walls of the blood-vessels, the blood coloring matter precipi- 
tates, and the lung becomes dense, of an iron-rust color, and contains 
abundant blood and serum, the condition known as broivn induration. 
Eupture of the pulmonary vessels also occurs, portions of the lung 
becoming engorged with blood and presenting a state of infarction 
resembling that caused by embolism. 

As the hypertrophy of the right side of the heart fails to force blood 
through the lungs, congestion of the peripheral venous system results. 
The distended jugular veins are apparent as dark-blue lines or cords, 
which are in constant motion in part from the transmission to the dis- 
tended vein of the impulse of the auricular contraction, in part from 
recurrent diminution in volume during inspiration. An actual venous 
pulsation synchronous with the systole of the heart exists when in tri- 
cuspid insufficiency the dilatation of the veins is sufficient to produce 
incompetence of the valves at the entrance of the jugular into the in- 
nominate vein. The smaller veins become dilated and tortuous, and the 
capillaries are so distended with blood that the skin, especially of the face, 
ears, fingers, and toes, becomes of a blue color. The nutrition of the tips 
of the fingers and toes is affected, and they become club-shaped. The 
first effect of the venous congestion of the liver is to produce such en- 
largement of this gland that the anterior border may be found below 
the level of the navel. The enlarged liver may receive and transmit 
the impulse from the aorta, which is to be distinguished from the ex- 
pansile pulsation due to venous engorgement in tricuspid insufficiency. 
With the persistence of the congestion destruction of the liver-cells and 
moderate increase of the fibrous tissue take place, finally resulting in 
the formation of the small pigmented liver known as the nutmeg liver. 
The obstruction to the passage of blood through the liver causes passive 
congestion of the radicles of the portal vein in the walls of the stomach 



662 



DISEASES OF THE CIRCULATORY APPARATUS. 



and the intestine, and chronic catarrah of the gastro -intestinal niucous 
membrane follows, which interferes with digestion and thns checks the 
effectual nutrition of the hypertrophied heart. 

In the early stage of portal obstruction the spleen is moderately en- 
larged, while in the later stage its density becomes increased, the process 
being similar to that which takes place in the liver. 

The check to the flow of blood from the kidneys interferes with the 
transudation of fluid through the glomeruli and causes the kidneys to 
become dense and purple, a condition to which the term cyanotic in- 
duration is applied. The quantity of urine is diminished, and its specific 
gravity is increased. There is an abundant brick- dust sediment, with 
occasional red blood-corpuscles, and perhaps a trace of albumin, which 
characteristics of the urine are indicative of a chronic passive congestion 
of the kidneys. 

As the result of prolonged congestion of the peripheral venous sys- 
tem, a transudation of fluid from the veins eventually takes place, and 
dropsy appears. The fluid in cardiac dropsy is usually first observed 
in that part of the body from which blood is returned to the heart with 
the greatest difficulty, — namely, in the feet, especially about the ankles. 
The oedema, therefore, in ambulatory patients, is at first noticed at the end 
of the day, disappearing during the night ; but with the increasing weak- 
ness of the heart the dropsy increases, and affects the thighs, the walls 
of the chest and abdomen, and the scrotum. Eventually fluid appears 
in the peritoneal, pleural, and pericardial cavities ; finally it is poured 
into the lungs, and then often proves the immediate cause of death. 

Among the most important of the complications of chronic valvular 
endocarditis is embolism. The formation of thrombi is promoted by the 
stagnation of the blood and an alteration of the surface over which the 
blood passes : hence they are present in those parts of the heart in 
which the current moves the slowest, namely, in the auricular appen- 
dages and in the intertrabecular recesses, which, in the dilated heart 
particularly, form pockets sunk into the wall. They arise also in the 
widened recesses above the valves of veins, especially of the legs and 
in the dilated and sacculated pelvic plexus of veins. The thrombi, 
becoming dislodged, are carried along as emboli, and produce the various 
phenomena of embolism according to their place of origin and distribu- 
tion. Yenous emboli and those from the right side of the heart, which 
are obviously the more numerous owing to the greater surface from which 
they may arise, follow the distribution of the pulmonary artery, and ac- 
cording to their size either produce sudden death when unable to pass 
into the primary divisions of the pulmonary artery, or give rise to large 
or small wedge-shaped masses of embolic infarction of the lungs. Em- 
boli transferred from the left side of the heart also cause sudden death if 
too large to pass through the mitral or the aortic orifice, and when small 
may reach the brain, causing aphasia or hemiplegia, or pass into the 



DISEASES OF THE ENDOCARDIUM. 



663 



spleen and produce a localized splenitis, more rarely obliterate the splenic 
artery and give rise to a secondary thrombosis of the splenic vein extend- 
ing to the superior mesenteric vein, usually ending in fatal hemorrhagic 
infarction of the intestine. If the emboli are carried to the kidneys, focal 
necrosis occurs, which may involve an entire kidney if the trunk of the 
renal artery is obstructed, the symptoms being those of an acute hemor- 
rhagic nephritis, or the emboli may be carried into the arteries of the 
extremities, producing temporary functional disturbance or necrosis and 
gangrene. 

Prognosis. — The prognosis of valvular endocarditis is more dependent 
upon general conditions than upon the valve concerned or the nature of 
its lesion. While compensation is satisfactory the immediate prognosis 
is favorable. The existence of causes which tend to enfeeble compensa- 
tion makes the prognosis correspondingly serious. In the valvular en- 
docarditis of children hypertrophy and dilatation rapidly progress, and 
compensation is earlier than in the endocarditis of adults, in whom com- 
pensatory hypertrophy is of more gradual occurrence and keeps a more 
uniform pace with the disturbances to be overcome. The endocarditis 
of elderly people, so frequently the result of arterio- sclerosis, may exist 
for years with but little disturbance, provided the general nutrition is 
relatively normal. The habits, exposure, and occupation of the person 
diseased are also important in prognosis. Excessive action of any sort, 
mental, moral, or physical, increases the demand upon a heart readily 
displaced from a condition of equilibrium, and sudden or prolonged 
strains often produce extreme disturbances of balance. Pregnancy and 
parturition act as continuous or temporary causes of increased work of 
the heart, and repeated child-bearing tends rapidly to weaken compen- 
sation. If puerperal infection follows childbirth, the localization of the 
bacteria upon an already diseased valve is of frequent occurrence. 

Disease of the valves, whether acute or chronic, local or general, 
increases the gravity of the prognosis of any disease, but especially of 
pneumonia, typhoid fever, or other severe or prolonged infection, of 
fibrous myocarditis, and of prolonged anaemia. The danger is less imme- 
diate provided the degenerated myocardium can be stimulated by the 
action of such a remedy as digitalis or strophanthus. 

Opinions differ as to the prognosis of chronic valvular endocarditis in 
relation to the valve affected ; but it is generally agreed that disease of 
the valves of the right side of the heart earlier proves fatal than that of 
the left, in consequence of the more immediate production of cyanosis 
and dropsy, the usual terminal symptoms of valvular endocarditis. Of 
mitral or aortic disease occurring before middle life, the former is sooner 
associated with evidence of failing compensation than the latter, and in 
general compensatory hypertrophy of the right ventricle yields earlier to 
disturbance of nutrition than hypertrophy of the left ventricle. Writers 
p:irticularly disagree as to the more serious import of stenosis or insuni- 



664 



DISEASES OF THE CIRCULATORY APPARATUS. 



ciency of the aortic and mitral valves. This difference of opinion probably 
depends in large part upon the fact that stenosis of the orifice is gener- 
ally, if not always, associated with incompetence of the valve, the degree 
of which varies within wide limits, whereas primary insufficiency of the 
valve is usually unaccompanied by obstruction at the orifice. Sudden 
death after middle life in the presence of effective compensation is more 
likely to occur in aortic insufficiency in consequence of the frequent 
simultaneous disease of the coronary arteries. Sudden death, however, is 
not infrequent in mitral stenosis, but when it does occur it is the result 
of embolism of the valve- orifice, or of the pulmonary artery from thrombi 
formed in consequence of the sluggish circulation in the later stages of 
failing compensation. The prognosis is always more unfavorable in 
combined valvular disease than in the affection of a single valve. 

MITRAL INSUFFICIENCY. 

The commonest of all the valvular affections is mitral insufficiency, 
which may occur alone or in combination with stenosis. The immediate 
effect is the regurgitation of blood into the left auricle during the con- 
traction of the left ventricle. This tends to prevent the reception of the 
normal amount from the pulmonary veins and to produce a diminished 
flow from the ventricle in systole. The auricle thus becomes overdis- 
tended, its cavity dilated, and its wall hypertrophied, although compen- 
sation is chiefly obtained by hypertrophy of the right ventricle. The 
signs of mitral insufficiency are, therefore, a systolic murmur, resulting 
from the regurgitation of the blood- current, and to be heard loudest at 
the apex. The murmur varies in intensity, but is increased on slight 
exertion, even on change of position, especially from the horizontal to 
the vertical. When loud it is to be heard elsewhere, especially in the 
axilla and the back. In rare instances it may be heard at the left of 
the sternum directly over the valve, and is sometimes continued into 
the diastole. According to the degree of alteration of the valve the 
murmur may or may not be accompanied by the first apex-sound. The 
area of cardiac dulness is increased, especially in the transverse direc- 
tion, and in extreme cases may extend from beyond the left inammil- 
lary line to the right of the sternum. In young persons with a yield- 
ing thoracic wall a bulging of the precordial area may exist. In con- 
sequence of the hypertrophy and dilatation of the right ventricle the 
apex-beat is intensified and perceptible over a greatly enlarged area, 
and the pulmonic second sound to be heard near the sternum in the 
second left intercostal space is strongly accentuated, on account of the 
increased pressure against the wall of the pulmonary artery. The 
aortic second sound is enfeebled from a diminished pressure against the 
aortic wall, and may be inappreciable at the apex. The pulse is of 
diminished volume and tension. There may be no symptoms for years, 
during which the compensation is sufficient, except on exertion, when 



DISEASES OF THE ENDOCARDIUM. 



665 



temporary shortness of breath and a quickened pulse occur. As com- 
pensation fails cyanosis occurs. 

Systolic murmurs often loud in character may be heard at the apex 
and be transmitted into the axilla independently of organic disease of 
the mitral valve. Such murmurs, functional or heemic, occur in a variety 
of diseases, even in robust persons in vigorous health, as shown by Prince 
in his examination of candidates for the position of fireman or policeman, 
but are not associated with increase in the area of cardiac dulness. 

MITRAL STENOSIS. 

Next in frequency to mitral insufficiency is stenosis of the mitral 
orifice, the immediate effects of which are essentially the same as those 
of insufficiency, — namely, dilatation and hypertrophy of the left auricle 
and hypertrophy and dilatation of the right ventricle. A diastolic mur- 
mur occurs as the left auricle forces blood into the ventricle, ending with 
the production of the first sound, increased on exertion, and is heard 
loudest at the apex. This murmur often increases in intensity at the 
end of diastole, and is perhaps first heard at this time ; it is, therefore, 
often called presystolic. The diastolic murmur is often associated with a 
systolic murmur from the frequent combination of insufficiency with ste- 
nosis. The area of cardiac dulness is increased laterally, and may extend 
from the right of the sternum to the mammiliary line. The apex-beat is 
usually felt in the fifth intercostal space in the vicinity of this line. The 
second heart-sound is frequently reduplicated, and Guttmann considers 
this an important diagnostic sign of mitral stenosis, since the duplica- 
tion is at times to be heard during the temporary absence of the murmur. 
In consequence of the hypertrophied right ventricle there is accentuation 
of the pulmonic second sound. Another important sign of mitral stenosis 
is the purring thrill, increasing on slight exertion, and to be felt near the 
apex. The pulse is weaker than in mitral insufficiency, and is usually 
irregular. The signs of congestion of the pulmonary and of the periph- 
eral veins occur earlier than in mitral insufficiency. 

AORTIC INSUFFICIENCY. 

In aortic insufficiency the ventricle becomes distended by the admis- 
sion of blood during the diastole both from the left auricle and from the 
aorta. An abnormally increased quantity of blood is thus constantly being 
received, which is to be expelled only by increased work : hence the 
ventricle becomes hypertrophied and the whole heart is enlarged. The 
physical signs are a prolonged diastolic murmur, continued downward 
towards the apex, heard with greatest intensity in the midsternal region, 
and sometimes extended to the right and left of the sternum. The second 
sound of the heart is either obscured by the murmur or is absent in 
consequence of the disease of the valves. A systolic murmur due to an 
associated narrowing of the orifice is sometimes also to be heard, especially 



666 



DISEASES OF THE CIRCULATORY APPARATUS. 



at the second right intercostal space, although it may be very faint. At 
the apex a systolic as well as the diastolic murmur is to be heard, either 
transmitted from the aortic orifice or resulting from organic or func- 
tional mitral incompetency. In the latter case the first heart-sound 
is not present at the apex. On auscultation of the carotid and sub- 
clavian arteries the diastolic murmur is sometimes transmitted, also a 
double murmur when existing at the aortic orifice, and the second sound, 
if present, is transmitted. If the arteries are compressed, a murmur is 
readily produced, and on pressure upon the femoral artery a double 
murmur and even two sounds may be heard. A systolic sound is to be 
heard on auscultation of the arteries, even of those at the wrist. 

The area of cardiac dulness is increased, especially in length, and 
may extend as low as the seventh rib and beyond the left mammillary 
line. The apex-beat may be found outside the nipple in the sixth in- 
tercostal space, and is perceptible over a wide area, heaving of the chest 
being associated with each beat of the heart. The visible and palpable 
arteries are dilated and tortuous, and pulsate strongly. The contraction, 
of the powerful left ventricle causes the arteries to be at once distended 
to the maximum, and an immediate fall of the tension results from the 
inability of the valves to hold the column of blood. This pulse, the 
water-hammer or Gorrigan pulse, is often more readily recognized at the 
wrist by holding the arm upright. The capillaries are frequently dis- 
tended and visibly beat, as may be seen in the pulsating flush of the 
cheeks or of the bed of the nail made anserine by pressure upon the nail, 
or of the everted lower lip through a piece of glass pressed upon the 
mucous membrane. 

Aortic insufficiency usually exists without symptoms for many years, 
owing to the efficient compensation caused by hypertrophy of the left 
ventricle. Palpitation is often not apparent, except on exertion, until 
compensation fails, when the attacks become more frequent. The palpi- 
tation may be associated with throbbing headache and wakefulness, and 
the patient be unable to lie on the left side. A feeling of faintness, 
especially on assuming the erect position, dizziness, and flashes of light 
occur. There is frequent pain referred to the region of the heart and 
sometimes extending into the left arm (angina pectoris), and dyspnoea 
is very troublesome. These symptoms are more and more easily induced 
by exercise or indigestion ; finally the mitral orifice becomes dilated, 
relative insufficiency occurs, and the symptoms of venous congestion of 
the pulmonary and body veins result. Death not infrequently takes place 
before relative insufficiency of the mitral valves occurs, either suddenly 
from cardiac paralysis, or more gradually from cerebral hemorrhage or 
arterial embolism. 

AORTIC STENOSIS. 

Aortic stenosis is the least frequent of the valvular affections of the 
left side of the heart, and, like mitral stenosis, is usually combined with 



DISEASES OF THE ENDOCARDIUM. 



667 



some degree of incompetency. The effect upon the ventricle is the same 
as that from aortic insufficiency, — that is, dilatation and hypertrophy re- 
sult, but the hypertrophy predominates over the dilatation. A systolic 
murmur is heard loudest near the third right costal cartilage and extends 
into the large arteries of the neck. The murmur is at times accompanied 
by a thrill, which when loud is to be heard throughout the cardiac area. 
The second aortic sound is often combined with a diastolic murmur, from 
the associated insufficiency. The area of cardiac dulness is increased 
downward and outward, but the increase is moderate in comparison to 
that resulting from aortic insufficiency. The apex-beat may be powerful 
and heaving or feeble and inconspicuous, according to the condition 
of the myocardium and the degree of hypertrophy. The pulse is of 
small volume, of increased tension, and usually of diminished frequency. 
During compensation aortic stenosis produces no symptoms. With fail- 
ing compensation palpitation, headache, dizziness, and faintness occur, 
followed by cardiac pain and dyspnoea as in aortic insufficiency. 

TRICUSPID INSUFFICIENCY. 

Tricuspid insufficiency when organic is usually the result of a foetal 
endocarditis, although in rare instances it may be due to endocarditis 
acquired after birth, in which case disease of the mitral or the aortic or of 
both valves is associated with it. Eelative insufficiency of the tricuspid 
valve is frequent, and is the usual result of mitral disease and sometimes 
of aortic endocarditis. Tricuspid insufficiency also follows diseases of the 
lung which prevent the flow of blood through the pulmonary artery, such 
as emphysema, fibrous pneumonia, and bronchiectasis. The blood regur- 
gitates into the right auricle, backs into the venge cavge, and produces 
engorgement of the veins of the body, with the effects already men- 
tioned. A systolic murmur is to be heard at the right of the lower part 
of the sternum and may extend outward from this region. The intensity 
of the second pulmonic sound is rather diminished than increased ; any 
resulting hypertrophy of the right ventricle is usually moderate, hence the 
transverse area of dulness is but slightly increased, and the apex-beat, 
though forcible, is neither diffused over a wide area nor much displaced. 
Especially important in diagnosis is the evidence of passive congestion of 
the veins of the body, characterized by the jugular pulse, which is most 
forcible in the right internal jugular vein and when the patient is on 
his back. Less frequent is the recognition of expansile pulsation of the 
liver from passive congestion of the branches of the hepatic vein. The 
symptoms of tricuspid insufficiency are cyanosis, dropsy, and the modi- 
fications in the secretion of urine already mentioned in the symptoma- 
tology of valvular endocarditis. These symptoms occur alone or are 
associated with those of respiratory disturbance, according as tricuspid 
insufficiency exists as a primary or as a secondary condition, indepen- 
dently or associated with pulmonary or other valvular lesion. 



668 



DISEASES OE THE CIRCULATORY APPARATUS. 



TRICUSPID STENOSIS. 

Tricuspid stenosis is extremely rare, and is usually of congenital ori- 
gin, though sometimes acquired after birth, in which case it is associated 
with mitral or aortic or both mitral and aortic disease. In consequence 
of the obstruction to the now of blood through the tricuspid orifice the 
right auricle is dilated and hypertrophied and the peripheral venous 
system becomes congested. A diastolic or a presystolic murmur is to be 
expected loudest near the ensiform cartilage, and is therebj 7 to be distin- 
guished from the murmur of mitral stenosis, which is to be heard near 
the apex. The effects of tricuspid stenosis are those of tricuspid insuf- 
ficiency, but are of more rapid occurrence. 

DISEASE OF THE PULMONARY VALVE. 

Endocarditis of the pulmonary valve is of extreme rarity, usually 
congenital, although possibly of traumatic origin from a severe strain 
after birth. A diastolic murmur loudest at the right of the midsternal 
region concealing the second sound of the heart is to be expected in pul- 
monary insufficiency. This murmur is sometimes associated with a sys- 
tolic murmur, which is to be differentiated from the murmur of aortic 
stenosis by the predominance of the symptoms of dilatation and hyper- 
trophy of the right ventricle and of disturbances of the pulmonary cir- 
culation. A palpable thrill has been recognized to the right of the 
sternum. Pulmonary stenosis is of more frequent occurrence, and is usu- 
ally associated with a perforated septum, patent ductus arteriosus, and 
other alterations of the heart, to which attention has been called on 
page 637. In pulmonary stenosis a systolic souffle is to be expected at 
the left of the sternum near the third costal cartilage, accompanied by 
palpable thrill and associated with hypertrophy of the right ventricle. 

Treatment of Chronic Heart Disease. 

Although chronic heart diseases vary greatly in the character and 
seat of the lesion, yet when viewed from a therapeutic stand-point all 
cases have so much in common that we have thought the treatment 
could be made most clear by a general discussion under one heading. 

There are three conditions of the heart as to power : first, that in 
which the power is excessive ; second, that in which the power is normal ; 
third, that in which the power is below the norm. For the sake of 
brevity, in this article the heart in which the muscle is excessive is 
spoken of as hypertrophied ; that in which the muscle is weak, as 
dilated : this entirely independently of the question whether the internal 
cavities of the heart are or are not increased in size. 

Although an altered valve or valve- opening can in no way be restored 
to its integrity, except in functional insufficiency, yet severe valvular 
disease may exist for many decades without giving serious inconvenience 
to its subject ; the reason being that there has been such increase in the 



DISEASES OF THE ENDOCARDIUM. 



669 



power of the heart-muscle as to compensate for the valvular disease. 
Thus, if there be such a leak at a valve as shall require x increase of 
power to overcome the loss of blood, it is plain that if the heart-muscle 
has gained exactly x power, little immediate evil will result from the 
diseased valve : such a heart is spoken of as having undergone ' 1 com- 
pensatory hypertrophy.' 7 If, however, the heart has gained only half 
x power, although it is absolutely hypertrophied, — i.e., enlarged and 
increased in power as contrasted with its normal self, — yet it is rela- 
tively dilated ; that is, it is decreased in power in proportion to the 
work required of it : such a heart may be spoken of as having under- 
gone " absolute hypertrophy," "relative dilatation." It- must, how- 
ever, be understood that the terms relative and absolute hypertrophy 
and dilatation are not used, and that when in this article a dilated or 
weak heart is spoken of the meaning is a heart weak for the work 
required of it. 

The diagnosis of the cardiac condition which is useful for the purposes 
of the therapeutist has to do not so directly with the nature or seat of 
the valvular lesion as with the relations between the increase of work 
and increase of power. The usual clinical diagnosis of the cardiac lesion 
is chiefly of practical value in assisting in making up the therapeutic 
diagnosis. 

A feeble murmur to the therapeutist is certainly as alarming as a 
loud murmur, because its feebleness very frequently depends upon lack 
of propulsive power, whereas a very loud murmur may in part be due 
to the fact that the blood is driven with force over the diseased valve. 
The indications of strength in the heart are strength and width of car- 
diac impulse, loudness and regularity of the heart-sounds, and fulness, 
force, moderate slowness, and regularity of the pulse. On the other hand, 
feebleness of the heart-sounds and of the impulse, rapidity, feebleness, 
and irregularity of the pulse, coldness of the extremities, and especially 
venous engorgement, are evidences of failing heart-force. Whenever 
there is a marked tendency to passive congestion of the lungs, to con- 
gestion and enlargement of the liver, to dropsical effusions of cardiac 
origin, heart-power is failing, and, whatever the valvular lesion may be, 
the treatment is that of cardiac dilatation. 

The only resources which we have for the treatment of cardiac hypo - 
trophy consist in the avoidance of such violent exercises as shall call the 
heart into excessive activity, and in the use of veratrum viride and 
aconite. The action of these two remedies upon the heart is very simi- 
lar : aconite is, however, more generally useful, because it is less apt to 
disturb the stomach, and because its influence is somewhat more per- 
sistent ; from one to two drops of the official tincture may be given 
three times a day. Larger doses are sometimes required, especially in 
times of excessive cardiac excitement ; although few patients will bear 
persistently more than three drops a day. 



670 



DISEASES OF THE CIRCULATORY APPARATUS. 



In the treatment of cardiac dilatation rest to the heart is of the utmost 
importance, and must be enforced with a rigor proportionate to the extent 
of the heart-failure ; in severe cases prolonged confinement to bed is 
essential, the secondary bad effects of the confinement being overcome, if 
necessary, by the use of massage and electricity ; sometimes avoidance 
even of intellectual excitement is so necessary that isolation and all the 
procedure of the rest-cure should be insisted upon. (See page 402.) In 
milder cases of heart-failure it may only be requisite to avoid violent 
exercise, such as hill-climbing, running up-stairs, etc. The opinion put 
forth by certain clinicians that a weak heart can be made strong by sys- 
tematic exercise of the heart we believe to be founded upon the con- 
founding of cases of true heart- weakness with those in which the heart is 
secondarily weak from the deposition and invasion of its tissues by fat. 

It is always important to attend carefully to the diet in a case of 
cardiac dilatation ; usually concentrated nutritious food, with only a 
moderate amount of farinaceous articles, is the best ; but when an active 
gouty diathesis, or a tendency to obesity, or other indication for the use 
of a special diet exists, the best results are to be obtained by the use 
of the diet best fitted for the needs of the system. Tobacco must be 
forbidden. Coffee is often deleterious. Malt liquors are to be used with 
great caution. 

The drugs which are directly useful in cases of dilatation are caffeine, 
the nitrites, strophanthus, digitalis, and strychnine. It is essential for 
the proper use of these drugs that the differences in their physiological 
actions be thoroughly understood. Caffeine is very feeble and uncer- 
tain in its cardiac action, and is never of any value in cardiac dilatation 
save as an adjuvant to the more positive cardiants ; as a diuretic it is the 
most active of the heart drugs, and is therefore especially useful when 
there is a tendency to suppression of the renal secretion or to dropsi- 
cal effusion. The nitrites when in small dose paralyze the inhibitory 
fibres of the vagi, and probably also stimulate the heart-muscle, so that 
very violent cardiac movements result ; the condition of stimulation, 
however, passes at once into one of dangerous sedation if the dose be 
increased beyond a certain point. Moreover, the nitrites, by paralyzing 
the vessel- walls, and probably also the vaso-motor centres, widen the 
blood-paths and lower arterial pressure. Evidently their use in chronic 
cardiac dilatation is very limited. Of the nitrites the amyl salt acts in 
the course of a few seconds after its exhibition, and releases the system 
from its influence in a few minutes. It is of no value in heart diseases 
save in certain brief crises. Nitroglycerin is distinctly less fugacious in 
its influence ; nevertheless, the action of a full therapeutic dose is mani- 
fested within two minutes after its ingestion, and ceases in about forty 
minutes : so that when given for a continuous effect nitroglycerin must 
be administered at least every hour. 

Strophanthus is primarily a muscle-poison, and is useful because the 



DISEASES OF THE ENDOCARDIUM. 



671 



muscle-fibres connected with circulation first feel its action. It is a 
powerful and very certain stimulant to the heart- walls, and probably also 
to the coats of the arterioles. It is absorbed rapidly, and acts quickly 
and persistently, but not with the peculiar permanence of digitalis. It 
should be given every four to six hours : the dose of the tincture is five 
to eight minims ; of the active principle strophanthin the dose is 0.0002 
gramme. In severe cases of cardiac failure strophanthus is less positive 
and certain in its action than is digitalis. Although it is undoubtedly 
capable of causing death as a poison, we have never seen other ill effects 
than gastric irritation, which invariably when an attempt is made to 
push the remedy in ascending doses soon becomes so severe as to create 
intolerance. 

Digitalis is absorbed very slowly and eliminated still more slowly, 
so that its influence upon the circulation may continue for days after the 
cessation of its administration. It acts as a powerful stimulant to the 
heart-muscle, to the peripheral pneumogastric nerves, to the vaso- motor 
centres, and to the muscle-fibres in the walls of the arterioles. As the 
circulation of the heart- wall suffers even more than the general circulation 
of the body when there is heart- failure, any cardiac drug which increases 
the activity of the circulation affects most favorably the circulation in 
the heart- wall, that is, the feeding of the heart-muscle, which in many 
cases has been at the same time overworked and underfed. Of all 
known drugs, however, digitalis is the most powerful in its permanent 
tonic effect upon the heart-nutrition. As has been shown by Gaskell, 
the period of diastole is that of repair of the heart- structure, and there 
seems to be no doubt that the pneumogastric nerve has a trophic func- 
tion, so that in the case of dilated heart digitalis brings more food (blood) 
to the heart- walls, prolongs the periods of structural upbuilding of the 
heart-muscle, stimulates the trophic nerve which dominates cardiac nu- 
trition, and by strengthening inhibition quiets nervous irritability. As 
a diuretic digitalis is inferior to strophanthus. 

The only disagreeable effect which is often produced by digitalis is 
disturbance of digestion. It is certainly true that the drug is capable of 
a cumulative action, although this is denied by recent authorities. In a 
case of pleuritic effusion in which digitalis had been given for ten days 
or more in large doses, no effect was apparent until one morning the 
pulse dropped from about 100 to 80 ; the remedy was withdrawn, but the 
pulse steadily fell until four days after the withdrawal of the digitalis 
it had reached 40 per minute, and at that rate it remained for several 
days before it began to mount towards the norm. The cumulative 
action of digitalis is to be chiefly feared when the drug fails to produce 
increased diuresis, and has been noted at various times immediately after 
tapping, for ascites, a patient who has been using digitalis very largely. 
The poisoning in these cases is without doubt produced by the absorption 
into the blood of liquid which has been lying in the tissues, the with- 



672 



DISEASES OF THE CIRCULATORY APPARATUS. 



drawal of external pressure from the abdominal vessels having brought 
about increase of lumen and consequent taking in of fluid. Neverthe- 
less, the cumulative action of digitalis is a rare phenomenon, and prob- 
ably never becomes dangerous provided the drug be withdrawn at the 
oncoming of the first symptoms. 

The slowness of absorption and of elimination of digitalis affects very 
materially the method of administration. Whenever there is a cardiac 
crisis and haste is necessary, hypodermic injections of the tincture should 
be employed. Ordinarily it is best to give the drug at intervals of from 
four to eight hours. Failure to obtain effects from it may be due to 
lack of boldness in administration. It should always be given cautiously, 
the pulse carefully watched, and the remedy withdrawn as soon as the 
beat falls below 85 (that is, if very large doses are being given) 5 no more 
of the drug being administered until its effects begin to vanish. 

There is much evidence in medical literature as to the superiority 
of the infusion over the tincture, but this apparent superiority rests 
simply upon the fact that ordinarily the infusion is given in much 
larger proportional dose than is the tincture. The tincture is ten times 
the strength of the infusion, so that six minims (ten to twelve drops) 
are equal to one fluidrachm of the infusion. The dose of the tincture 
may be set down as from five drops to a fluidrachm, that of the infusion 
from a fluidrachm to a fluidounce. Digitalin is a complex substance : as 
kept in the drug-stores it is of various composition, and cannot be relied 
upon as a representative of digitalis. Digitoxin has been used by some 
clinicians, but the experiments of Kobert indicate that it does not thor- 
oughly represent digitalis, and we have never employed it. 

Strychnine is a valuable drug in cases of heart-failure as an adjuvant 
to digitalis or strophanthus. Its influence upon the circulation is not, 
however, comparable to that of the remedies just mentioned, and its 
effects are never very pronounced. It may be given in much larger doses 
than those commonly used ; ordinarily in a bad case with cyanosis one- 
fifteenth or even one-twelfth of a grain every four hours may soon be 
reached by ascending doses without the production of any symptoms of 
strychnism. 

Cocaine resembles strychnine very closely in its action, and in bad 
cases it may be well to give it alternately with strychnine in one- quarter- 
grain doses. 

In regard to what may be called the " minor heart drugs/' ammonia 
is sometimes useful in a crisis ; it is, however, such a powerful local 
irritant that it can scarcely be safely used in sufficient dose to produce 
distinct immediate effect : most of the restoration of heart- function which 
is apparent under its influence is really reflex, due to irritation of the 
peripheral nerves in the nasal or other mucous membrane. At best the 
influence is so fugacious that it is only in a crisis that the drug is of any 
use. 



DISEASES OF THE ENDOCARDIUM. 



673 



Cactus, convallaria, and adonidin have failed us utterly, and seem to 
have no practical value. Sparteine has been very highly recommended 
by Pawinski and Clarke as having especial power in controlling nervous 
palpitation, even in Graves's disease. The official sulphate may be given 
in doses of one-fourth grain, increased cautiously to two grains, if neces- 
sary, every six to eight hours. Our experience with it has not been very 
favorable. 

As adjuvants to the more powerful remedies, alcohol, ether, or Hoff- 
mann's anodyne may be used freely in cases of sudden heart-failure. 
They may be given hypodermically, but produce much local irritation, 
and are so readily absorbed from the stomach that it is usually preferable 
to give them by the mouth. In Germany camphor is very much used as 
a rapidly acting heart-stimulant by subcutaneous administration ; the 
ten per cent, solution in olive oil of the German Pharmacopoeia may be 
injected in closes of one-half to one nuidrachm, or a solution of camphor 
in ether may be employed. 

Success in the treatment of heart disease depends largely upon the 
management of the secondary conditions produced by the cardiac lesion. 
The portal circulation very frequently becomes the seat of excessive con- 
gestion, which may manifest itself chiefly in derangement of the function ; 
with it there may be a pronounced increase in the size of the liver. 
Under these circumstances there is no remedy of equal rank with the 
mercurials. The vegetable cathartics, which are alleged to have active 
cholagogue power, are of very little value. Sodium phosphate, especially 
the mixture of sodium sulphate and sodium phosphate with potassium 
iodide (see formula 19), is often of service. Mtrohydrochloric acid is 
sometimes useful. All these drugs, however, are entirely secondary to 
the mercurials. Very frequently purgative doses of calomel bring the 
greatest relief ; it may even be that the calomel is followed by a favor- 
able action of the digitalis which had previously been without avail. 
Perhaps more often the continuous use of small doses of corrosive sub- 
limate (one-twentieth to one-eightieth of a grain) has a very happy effect. 
In many cardiac cases iron is indicated for the relief of the secondary 
anseinia ; under such circumstances usually the tincture of ferric chloride 
with corrosive sublimate gives the best result. 

Treatment of Special Conditions. 
Early Weeks of Valvular Disease.— It is especially important when 
an acute endocarditis is passing into valvular lesion that great care be 
exercised to favor the development of compensatory hypertrophy. Ex- 
cessive hypertrophy is a very rare phenomenon when the valvular lesion 
has been rapidly induced by an endocarditis. Eest, fresh air, carefully 
graded exercise, high feeding, and the habitual use of digitalis in small 
doses are the means at our disposal for increasing the working power of 
the heart which has been damaged by acute inflammation. Digitalis is 

43 



674 



DISEASES OF THE CIRCULATORY APPARATUS. 



in these cases much superior to strophanthus, on account of the greater 
trophic influence which it exerts upon the heart. There are practitioners 
who condemn the use of digitalis in the early or formative stage of cardiac 
valvular disease. Nevertheless, its power for good is in many cases at 
this time greater than at any other, and it is certainly when properly 
used incapable of harm in most cases in which the valvular lesion has 
been produced by an endocarditis. It is so rare for compensation in 
such cases to become excessive that the danger of cardiac hypertrophy 
may be considered almost nothing ; if, however, there should be signs 
of excessive cardiac growth, digitalis should be omitted. In no instance 
should it be given in such dose as to produce an habitual pulse of 
under 75. When under care compensatory hypertrophy has been ob- 
tained, or when in any case an organic cardiac murmur associated with 
compensatory hypertrophy is unexpectedly discovered, the administra- 
tion of heart tonics should be avoided, unless at intervals when temporary 
derangement of the health brings the circulation below the normal level. 

The question whether an individual should be told that he has a heart 
disease or not is often of somewhat difficult solution : probably in the 
majority of cases it is better to give a careful warning, along with the 
statement that cases of heart disease often live comfortably for decades 
of years, because in no other way can the patient be led to the well- 
regulated life that is necessary for his .continuous good. Under these cir- 
cumstances violent muscular exercise should be interdicted ; care should 
be exercised in allowing the patient to go into high altitudes ; daily tepid 
or cold baths should be taken, the Turkish and very hot baths being 
avoided as dangerous if there is distinct heart- weakness. Tobacco is not 
allowed ; alcohol should be used very moderately, if at all. 

Acute Cardiac Dilatation. — An acute attack of cardiac dilatation 
or failure, if of severe type, may be due to the blocking up of a branch 
of the coronary artery. If the branch is a large one, a fatal result 
is inevitable ; if it is small, recovery may occur, though the symptoms 
at first may be very severe. Severe attacks of sudden cardiac failure 
may occur in valvular disease with or without apparent cause ; they 
are to be recognized by the heart-pangs, shortness of breath, irregular 
forced respiration, rapid feeble broken pulse, and evidences of venous 
congestion. When these symptoms develop with great rapidity, when 
signs of venous engorgement are pronounced, and orthopnoea exists with 
cyanosis, the taking of twenty to thirty ounces of blood by venesection 
has long been recommended by standard authorities. We believe this 
teaching to be correct, but it is plain that such venesection cannot be 
repeated, and that its use must be reserved for crises in which the di- 
lated feeble heart is so close to the point of giving up the struggle to 
move the large amount of blood in the body that the effect of the more 
usual treatment cannot be waited for. (See page 675.) In some cases, 
especially when there is a tendency to dropsical effusion, it is possible 



DISEASES OF THE ENDOCARDIUM. 



675 



to reduce the volume of blood sufficiently by rapid free purgation. The 
ordinary treatment of acute heart- failure with backing up of the blood 
in the pulmonary vessels, resulting in pulmonic oedema with frothy 
bloody expectoration, may be summed up as follows : first, the use of 
absolute rest ; second, the administration subcutaneously of small doses 
of morphine and atropine to quiet the nervous system $ third, the free 
administration of alcoholic stimulants by the mouth, the guarded use of 
nitroglycerin, which dilates the general blood-vessels of the body and 
probably lessens the amount of work necessary for the left ventricle, the 
hypodermic injection of strychnine, the inhalation of oxygen gas, which 
may increase oxidation in the blood and certainly does not strongly sup- 
port the patient morally, and, finally, the free use of digitalis. Owing 
to the ease with which the stimulating action of nitroglycerin passes 
into cardiac sedation, large doses of nitroglycerin are very dangerous. 
Of all the drugs digitalis is the most efficacious : it must be used 
in large doses. From twenty to thirty minims of the tincture may 
be given every two hours if required ; in a crisis thirty minims of 
the tincture may be given immediajfcely hypodermically : the danger of 
local effects is lessened by not injecting more than fifteen minims in one 
place. 

In the advanced stages of chronic cardiac disease, when the heart 
seems entirely unable to do its work, relief will often be afforded by 
the use of a drachm or more of tincture of digitalis every twenty-four 
hours, the remedy being withheld for one or two days each week to prevent 
accumulation, and the dose lowered whenever it can be done without 
suffering. It should be remembered that these large doses are justifiable 
only when life cannot otherwise be made comfortable. We have fre- 
quently seen patients who for many weeks had suffered all the horrors of 
orthopncea, notwithstanding various treatment, including the moderate 
use of digitalis, put upon their feet by massive doses of the drug and 
even enabled to resume their vocations. It is essential, however, to di- 
minish the dose as soon as possible ; in our experience, patients who have 
been kept going by the use of these very large doses of digitalis have in 
the end almost invariably dropped dead. It is not probable that these 
sudden deaths were due to any direct action of the drug upon the heart j 
they were probably the result of the use by the heart of all the forces 
within its power. Such cases are frequently paralleled in heart diseases 
where the patient has remained comfortable and suddenly expired without 
digitalis having been given. In any event, in our opinion, months of 
ease with sudden death at the end are to be preferred to a probable 
shorter period of excessive suffering. 

Valvular Lesions. — The treatment of all forms of valvular lesions is 
simply that of the accompanying muscle condition. The seeming truth 
in the old teaching that digitalis is not useful in diseases of the aortic 
orifice is due to the fact that aortic disease is in the majority of cases 



676 



DISEASES OF THE CLRCTTLATOHY APPARATUS. 



of gradual development, and is, therefore, very prone to be accompanied 
with completely compensatory or excessive hypertrophy. Again, digitalis 
is most satisfactory in mitral insufficiency because in these cases the open- 
ing in the closed valves is apt to be small, irregular, and much choked 
up by vegetations or fimbriations. If under such circumstances by the 
use of digitalis the amount of blood thrown out at a single stroke and 
the power of ejection are simultaneously increased, friction increases at 
the rough, narrow chink in the closed mitral valve much more rapidly 
than it does at the wide, open, smooth, aortic orifice, so that a much 
smaller percentage of blood flows back through the valve than was the 
case before the exhibition of the digitalis. Cases of mitral iD sufficiency 
are occasionally met with in which the heart-muscle is distinctly feeble 
and compensation failing, but in which digitalis in full dose increases very 
greatly the heart-pang and general distress. In most, if not all, of these 
cases it will be found that the left auricle is excessively dilated and is 
unable to withstand the increased strain thrown upon it by the forcible 
regurgitant flow under the use of digitalis. In all the cases of this char- 
acter which we have seen the result has proved that the situation was 
from the first desperate and without remedy. 

Treatment of Symptoms. 
Cardiac palpitation and distress are usually best controlled by appro- 
priate cardiants : in excessive hypertrophy with throbbing, aconite ; in 
the distressing pain in heart-failure, digitalis ; when with the pain there 
is high tension, as when arterio-sclerosis coexists with cardiac disease, 
nitroglycerin is often most serviceable. The local application of ice- 
bags and of various counter-irritants, such as mustard plasters and flying 
blisters, sometimes gives relief. Hoffmann's anodyne is temporarily effi- 
cient ; a teaspoonful of it should be given in a wineglass of ice-cold 
water. Hypodermic injections of morphine, with atropine, are most 
valuable and efficacious subduers of heart-pain. (See also Angina Pec- 
toris, page 684.) Insomnia and the horrible night restlessness which 
sometimes occurs in heart disease are to be met by the cautious use of 
potassium bromide, of trional, of sulphonal, of chloralamide, of paralde- 
hyde, and of other of the minor somnifacients. An alcoholic potation, 
especially if combined with camphor, sometimes suffices. Chloral is 
very effective in producing sleep, but is certainly dangerous in full dose 
when there is cardiac weakness, and if used habitually is apt to weaken 
still further the force of the circulation : it should therefore usually be 
avoided. Cough and haemoptysis may ordinarily be left to nature, but 
if they become severe should be controlled in the ordinary method ; a 
moderate hemoptysis is in many cases beneficial, by temporarily re- 
lieving pulmonic engorgement. Indigestion and vomiting are usually 
to be treated by remedying the hepatic and general portal congestion. 
Bitter tonics are rarely of service. When the vomiting is severe, creo- 



DISEASES OF THE ENDOCARDIUM. 



677 



sote, hydrocyanic acid, bismuth, cerium oxalate, cocaine, and the other 
well-known anti- emetic remedies may be tried. Very often the chief 
reliance must be upon opium suppositories. Excessive cardiac dyspnoea 
or orthopnoea, being the direct result of failing heart-power, is to be 
chiefly combated by the use of cardiac tonics and stimulants, aided, if 
the lungs be violently congested, by the use of dry cups or other forms 
of counter-irritation. Strychnine and cocaine are indicated ; the inhala- 
tion of oxygen gas rarely, if ever, does any good. 

For getting rid of dropsical effusions in cardiac cases, purgatives, 
diaphoretics, or diuretics are employed ; of these the first named are 
the most efficient, but they are very exhausting to the patient. The 
choice of purgatives lies between the salines, notably sodium or mag- 
nesium sulphate or potassium and sodium tartrate ; the last of these is 
the most pleasant to take, but is the least powerful. Salines, if used at 
all, are best given in concentrated solution. Compound jalap powder 
(thirty grains) is a very effective hydragogue cathartic, which may, how- 
ever, be made more serviceable by the addition of two drachms of cream 
of tartar to the dose. Elaterium acts very kindly if given with extract 
of belladonna (one-sixth of a grain of each) and repeated every four to 
six hours as necessary. Of these purgatives we have preferred the 
last ; other practitioners habitually use the salines ; either remedy may 
be employed. 

Diaphoretics are not usually effective in cardiac dropsy. The hot 
bath, whether in the form of the vapor bath (Eussian), or the dry-air 
bath (Turkish), or the simple hot- water bath, is dangerous, and should 
be used cautiously or be altogether avoided if the heart is very weak. 

Diuretics often act happily, provided the circulation of the kidneys 
can be, in a measure, restored by cardiac tonics. Of these cardiants 
strophanthus is very active as a diuretic, but is as such inferior to caffeine, 
whose heart-action is, however, very feeble. Potassium bitartrate, an 
ounce a day in a pint of infusion of juniper or of water containing two 
or three ounces of the compound spirit of juniper, is the most active 
of the sedative diuretics, soothing rather than irritating to the kidneys. 
Sodium and theobromine salicylate, and pilocarpine hydrochlorate (one- 
twentieth of a grain every two hours), are active diuretics which do not 
irritate the kidneys. Scoparius in full dose is one of the most certain of 
its class, but is somewhat irritant ; it is best given in the form of the 
decoction, made by boiling for ten minutes one ounce of the dried broom- 
tops with a pint of water and straining ; dose, one-half pint to a pint 
during twenty-four hours. Squill is irritating to the kidneys, but very 
useful in many cases of cardiac dropsy, especially in the old pill of one 
grain each of calomel, squill, and digitalis, taken three or four times a 
day. The Jendrassik method of using calomel may succeed after other 
remedies have failed : five grains of calomel are to be exhibited every 
hour until fifteen are taken, or three grains of the calomel may be given 



678 



DISEASES OF THE CIRCULATORY APPARATUS. 



every four hours until free diuresis is obtained or severe intestinal dis- 
turbance is induced. 

In some cases of cardiac dropsy relief may be obtained by mechan- 
ical means. Thus, oedeinatous legs may be bandaged with canton flannel, 
or, if the weather be cold, in wool flannel. Paracentesis abdominalis 
is rarely required : puncturing the legs, the introduction of Southey's 
tubes, and the making of moon-shaped incisions below the internal mal- 
leoli, are procedures which may be forced upon the practitioner, but 
are to be put off as long as possible : strict antiseptic precautions should 
always be taken in their performance. 

CARDIAC NEUROSES. 

PALPITATION. 

By this term is understood an increased beat of the heart, producing 
sensations disagreeable to the patient. Palpitation occurs in healthy 
persons of nervous temperament as well as in sufferers from disease of 
the heart, in whom it is one of the serious symptoms of failing compensa- 
tion. Palpitation as a cardiac neurosis is more common in women than 
in men, and is especially likely to be excited at the age of puberty, 
during the climacteric, or in connection with disturbances of menstrua- 
tion. The prolonged use of tea, coffee, tobacco, or alcohol, mental over- 
work, sexual excesses, digestive disturbance, pelvic disease, exophthalmic 
goitre, chlorosis and anaemia, and prostration during convalescence from 
severe acute disease, act as predisposing causes. The immediate parox- 
ysm may be produced by mental or physical excitement, by an attack 
of indigestion, or without any obvious excitant. Palpitation occurs at 
irregular intervals and lasts for a longer or shorter time. The accelerated 
beating of the heart is usually apparent on inspection of the carotids and 
of the cardiac region, but the action of the heart, though rapid, may be 
feeble, and the patient complain of sensations of faintness. The in- 
creased pulsations are often associated with a feeling of substernal oppres- 
sion, perhaps of choking. The face is generally flushed, though some- 
times pale, and the expression is anxious. On examination of the heart 
during the attack the sounds, especially the second, though usually ac- 
centuated, are sometimes feeble, and systolic murmurs may be heard at 
the base. Da Costa has called attention to recurrent attacks of palpi- 
tation and precordial pain, particularly among soldiers, but also to be 
found among other persons. He applies the term irritable heart to this 
condition, attributing the attacks to strain and overaction of the heart, 
and states that among soldiers they are especially likely to follow fatiguing 
marches, and that permanent dilatation may result. Palpitation inde- 
pendent of organic disease, though disagreeable, is rarely dangerous. 

Treatment. — In the treatment of palpitation of the heart not due to 
disease of the viscus, it is essential first to discover, and then, if possible, 



CARDIAC NEUROSES. 



679 



to remove, the cause. When this has been done, in a large proportion of 
cases no farther difficulty is experienced, so that the palpitation does not 
require any direct treatment. If, however, at any time there is distress 
with the palpitation, camphor or Hoffmann's anodyne may be given in 
full dose, and in some cases the persistent administration of small doses 
of tincture of aconite or of tincture of digitalis will be found useful. 
Theoretically the choice between these two remedies is to be made in 
accordance with the condition of the heart as to power j but practically 
in many cases the final selection must be the result of trial, that medica- 
ment being selected which affects most satisfactorily the individual case. 

In irritable heart the avoidance of all exertion or emotion that would 
provoke cardiac excitement should be the basis of the treatment. The 
patient should be made to understand that the affection is serious and 
may lead to permanent alteration of structure, so that the temporary 
inconvenience of prolonged rest shall be willingly endured. In perhaps 
the majority of these cases the best results are to be obtained from the 
continuous administration of aconite ; but when there is any tendency to 
failure of heart-power digitalis should be used in such doses as may be 
required. 

TACHYCARDIA. 

Eapid beating of the heart is usually considered to be the result of a 
disturbance of innervation of the cardiac ganglia, attributable either to 
disease of the ganglia themselves or to paralysis of the pneumogastric or 
irritation of the sympathetic nerves. Martius considers that tachycardia 
is due to a sudden dilatation of the heart, which is frequently associated, 
the pulsations being quickened that the heart may be emptied. The im- 
mediate causes of tachycardia are the same as those productive of pal- 
pitation, and in addition organic disease at the origin or in the course of 
the pneumogastric nerve is important. Like palpitation, its occurrence 
in disease of the heart belongs to the stage of failing compensation. 

In paroxysmal tachycardia attacks of rapid beating of the heart, the 
pulse rising perhaps above two hundred beats, continue to recur for an 
hour or more at frequent intervals during a period of weeks, months, or 
years, the patient being free from disturbances in the mean time. The 
attacks are accompanied by nausea, prostration, and anxiety, and are 
sometimes relieved by belching of gas or by an evacuation of the bowels. 
H. C. Wood reports the case of a physician eighty-seven years old in 
whom violent attacks had frequently recurred for fifty years without 
causing any disturbance of health or interfering with a very active life. 
Paroxysmal tachycardia must be considered to be a distinct neurosis 
whose pathology is at present inexplicable ; though persistence of the 
attacks may result in permanent dilatation. In the case above mentioned 
the paroxysms could be immediately aborted by rapidly drinking a 
tumbler of very cold ice-water. No known treatment has any effect 
upon the recurrence of the attacks. 



680 



DISEASES OF THE CIRCULATORY APPARATUS. 



BRADYCARDIA. 

Bradycardia, or slow beating of the heart, is attributed to irritation 
of the pneumogastric nerve, or to paralysis of the branches of the sym- 
pathetic nerve which accelerate the action of the heart, or to irritation 
or paralysis of the nerve-centres within the heart. It is more common in 
men than in women, and in adults than in children. A physiological is 
to be distinguished from a pathological bradycardia. The former (normal 
bradycardia) is found in certain people, and often in old age. In like 
manner the frequent occurrence of bradycardia after delivery is hardly to 
be regarded as pathological, and during convalescence from fever it is on 
the border-line between the physiological and the pathological variety. 

Bradycardia as a symptom of disease may be due to a variety of lesions 
affecting the nervous system and the heart, or to a toxa3mia. Among the 
diseases of the nervous system are meningitis, hemorrhages, intra- cranial 
tumors, affections of the cervical portion of the spinal cord, mania, 
melancholia, and paralytic dementia. More often the lesions are present 
in the heart, and include sclerosis of the coronary arteries, chronic myo- 
carditis, fatty degeneration of the heart, and aortic and mitral disease. 
According to Dehio, the persistence of bradycardia despite the use of 
atropine is evidence of its cardiac origin. The toxic causes are tea, 
coffee, tobacco, alcohol, opium, digitalis, carbonic acid gas, lead, the poi- 
sons present in uraemia and diabetes, and the bile-acids in jaundice. The 
bradycardia in convalescence from acute infectious diseases, as typhoid 
fever, acute rheumatic arthritis, pneumonia, diphtheria, erysipelas, 
malaria, and in diseases of the digestive tract, as ulcer or cancer of the 
stomach, has been attributed both to toxaemia and to exhaustion. In like 
manner its occurrence in starvation is a result of prolonged exhaustion. 
In normal bradycardia the pulse-rate rarely falls below forty, but in ab- 
normal bradycardia the beat may be less than ten strokes. According 
to the degree of slowness of the pulse and the corresponding quantity of 
blood distributed at each systole are the character and frequency of asso- 
ciated symptoms. These usually occur in paroxysms induced by mental 
or physical excitement, perhaps by acute indigestion, and the attacks 
continue for several minutes or for a half-hour or more. Cerebral 
anaemia often follows, manifested by fainting, loss of consciousness, or 
epileptiform convulsions. Indeed, so-called senile epilepsy is a frequent 
result of paroxysms of bradycardia in elderly persons with sclerosis of 
the coronary arteries or fibrous myocarditis. The respiration may be 
simultaneously diminished, and sometimes assumes a Cheyne- Stokes 
character. When the attack is recovered from, a considerable degree of 
exhaustion ensues. Bradycardia is of grave prognostic importance when 
due to disease of the heart or brain, although this symptom may be 
continued over a period of several years. Moreover, as in several cases 
reported by the elder Flint, bradycardia may end in death, and a care- 



CARDIAC NEUROSES. 



681 



ful post-mortem examination may fail to detect any cause. These are 
probably diseases of the cardiac ganglia entirely beyond our ken. When 
due to cardiac disease, dilatation is the uniform result of the disturbed 
action of the heart. If death ensues, it may be sudden or gradual from 
cardiac insufficiency. 

Treatment. — Whenever a cause can be assigned for an existing 
bradycardia it should be removed, if possible ; further than this the 
treatment is very unsatisfactory. Whenever there is any feebleness of 
the heart, rest and total avoidance of heart-strain should be rigidly 
enforced, and under such circumstances strophanthus may be very care- 
fully tried. In those cases which may be for the present denominated 
" essential bradycardia,' 7 in which no explanation of the symptoms can 
be made out during life or detected after death, there is no known 
remedy. For the slowness of the pulse-beat due to pneumogastric irrita- 
tion large doses of atropine may be indicated ; but in a case in which the 
pulse fell to four a minute, and in which on three or four occasions the 
patient was pronounced dead, neither belladonna nor any other known 
cardiant had the slightest apparent influence, although given very freely : 
finally, under rest, recovery of the heart-rate occurred. 

ARHYTHMIA. 

Alterations of the rhythm of the heart are considered to result from 
faulty innervation, and may be found in persons otherwise normal as well 
as in those diseased. The pulse of defective rhythm is usually spoken of 
as intermittent or irregular. Baumgarten divides the causes of irregu- 
larity into those originating in the brain or heart and those of reflex origin. 
The intra-cranial causes are cerebral concussion, hemorrhage, softening, 
abscess, meningitis, and psychical disturbances. Those proceeding from 
the heart are the result of disturbed nutrition or of the action of poisons. 
The disturbances of nutrition occur in fevers, wasting diseases, coronary 
sclerosis, fibrous myocarditis, valvular disease, and cardiac strain. The 
abuse of tea, coffee, tobacco, and alcohol, and the action of various drugs, 
especially digitalis, belladonna, and aconite, are among the toxic causes, 
and the reflex causes are to be found in blows upon the abdomen, acute 
and chronic digestive disturbances, and diseases of the kidney. Numer- 
ous variations in the irregularity of rhythm are to be recognized. In 
the paradoxical pulse of Kussmaul the pulse is accelerated and less full 
during inspiration than in expiration, sometimes stopping at the end of 
prolonged inspiration. This variety occurs not only in fibrous pericar- 
ditis and mediastinitis, but also when there is abundant exudation, and 
in mediastinal tumor and in obstruction of the air-passages. It may be 
observed in sleeping children. In the intermittent pulse the beats of the 
heart are not transmitted to the wrist, and in the deficient pulse the heart 
occasionally fails to contract, and thus a beat is lacking from time to 
time. An alternating pulse is present when the volume of every other 



682 



DISEASES OF THE CIRCULATORY APPARATUS. 



beat is full or diminished. In the bigeminal and trigeminal pulses every 
second or every third beat fails to reach the wrist, hence every two or 
every three beats are separated by an abnormally long interval. In 
delirium cordis the beat of the heart is wholly irregular in force, in fre- 
quency, and in the interval between the beats. 

Occasional irregularity of the pulse is less indicative of a serious 
disturbance than is persistent irregularity ; when occurring in infants or 
elderly people it is of no necessary pathological significance, marked 
degrees of irregularity being compatible with prolonged and active life. 
Even in cardiac disease the arhythmical pulse may be present at a time 
when there is satisfactory compensation, though usually it is a sign of 
failing compensation. The extreme irregularity of delirium cordis, how- 
ever, occurs in the later stages of failing compensation, and is a grave 
prognostic sign, since it not infrequently ends in sudden death. Car- 
diac arhythmia calls for no treatment other than that of the condition 
upon which it depends. 

ANGINA PECTORIS. NEURALGIA OF THE HEART. 

Definition. — A paroxysm of intense pain in the region of the heart, 
associated with a sense of impending death. 

The term angina pectoris applies rather to a group of symptoms than 
to a definite disease, usually occurring after middle life, and more fre- 
quently among men than among women. The most frequent cause is 
sclerosis of the coronary artery, but it may result from chronic aortic 
stenosis or insufficiency, aneurism of the arch of the aorta, fatty degen- 
eration of the heart, or chronic adhesive pericarditis. A distinction is 
drawn between true angina and pseudo-angina, the latter occurring more 
frequently in young adults of nervous temperament, especially in the 
neurasthenic and hysterical, although the causes of the immediate attack 
may be the same as in true angina. The attacks of pseudo-angina are also 
occasioned by the abuse of tea, coffee, or tobacco, and by lead poisoning, 
and are more likely to occur in persons suffering from prolonged disturb- 
ance of digestion. Nothnagel has applied the term vaso -motor angina to 
attacks of substernal constriction and pain referred to the heart, associ- 
ated with a pale, bluish-gray color of the cool skin and a sense of mus- 
cular stiffness. This condition is assumed to be the result of a spasm 
of the peripheral arteries, and is apparently simply a variety of pseudo- 
angina in which vaso-motor disturbances are conspicuous. 

Symptoms. — The severer attacks of angina pectoris are usually pre- 
ceded, perhaps for years, by what are essentially milder attacks, — namely, 
a sense of oppression beneath the sternum, slight pain at the apex, and 
some shortness of breath on slight exertion. Such discomforts are in- 
duced by mental or physical excitement or by indulgence in alcohol or 
tobacco, or follow slight disturbance of digestion. These milder attacks 
of angina gradually increase in severity until typical paroxysms occur. 



CARDIAC NEUROSES. 



683 



Under the effect of similar causes, sudden, unexpected, often intense 
pain arises, referred to the region of the heart and associated with a sense 
of oppression in the midsternal region. The pain is primarily referred 
to the cardiac plexus of nerves, from which it radiates frequently into the 
left shoulder, neck, and arm, in the latter often following the course of 
the ulnar nerve to the fingers, which, as well as the arm, are perhaps 
benumbed. More rarely the pain extends into the right arm or shoots 
up and down the chest, sometimes extending to the lower extremities. 
During the attack there are great anxiety and fear of impending death. 
The patient grasps a support if within reach, and remains stationary, 
fearing to draw a long breath, although there is no real dyspnoea. The 
face is pale, the skin is moist, and the pulse is usually increased in fre- 
quency, weak and irregular, but the second aortic sound may be of in- 
creased tension. The attack rarely lasts longer than a minute or two, 
although it may be frequently repeated during a series of hours. The 
patient may feel faint or lose consciousness, and the paroxysm not infre- 
quently ends with belching, vomiting, or an evacuation of the bowels. In 
the course of a few minutes after the pain has disappeared the patient 
may feel as well as usual, or hours of exhaustion may follow. Although 
in general the physical examination of the heart is negative, dilatation, 
especially of the left ventricle, is likely to occur if the angina is con- 
tinued over a period of years. The symptoms of obstruction of the pul- 
monary circulation then are manifested, and the attacks of angina may 
be associated with the signs of acute insufficiency of the left ventricle, — 
namely, dyspnoea and a frothy, bloody sputum from extreme congestion 
of the lungs. 

Diagnosis. — The symptoms of angina are sufficiently characteristic, 
but their significance largely depends upon the evidence of associated 
organic disease of the heart, of its vessels, or of the aorta. True angina 
occurs more frequently among men beyond middle life in consequence 
of unusual mental excitement or physical exertion, is of short duration, 
and at times is associated with a pulse of increased tension from arterio- 
sclerosis. Pseudo-angina takes place especially at night, and chiefly 
among neurasthenic or hysterical young women or men suffering from 
dyspepsia. The attacks last for a half- hour or more, pain and fear of 
death being less conspicuous than a sense of constriction and palpita- 
tion, and end with the frequent desire for micturition. The cases of 
especially doubtful diagnosis are those of pseudo-angina with evidence 
of cardiac disease, when it may be necessary to reserve one's opinion 
until treatment has made the distinction clear between the true angina, 
dependent upon organic disease, and the pseudo-angina, which practi- 
cally is an exaggerated form of nervous palpitation. 

Prognosis. — The prognosis of true angina, whether mild or severe, 
is always serious, since progressive organic lesions are the usual cause, 
and increasing dilatation, perhaps myomalacia, of the left ventricle, is the 



684 



DISEASES OF THE CIRCULATORY APPARATUS. 



result. Mild attacks may suddenly terminate fatally from thrombotic or 
embolic obliteration of the coronary artery, from rupture of the heart, or 
without any obvious anatomical lesion. The pathological importance of 
obstruction of the coronary artery is demonstrated by the experimental 
production of complete closure of the left coronary artery, the effect of 
which is paralysis of the left ventricle, followed by dilatation and imme- 
diate death, or by rapid breathing, congestion, and oadema of the lungs. 
On the other hand, attacks of angina associated with cardiac lesions may 
continue for many years, and the patient with suitable care and proper 
treatment may live to a good old age. The prognosis in the individual 
case is the better provided there is no evidence of disease of the aorta, 
of the aortic valves, or of the myocardium, and the pulse is regular and 
without high tension. The prognosis is also more favorable the fewer 
and the milder the attacks, especially when the patient is able largely 
to control his surroundings. 

Treatment. — The energy of treatment in heart-pang should always 
vary with the severity of the symptoms. During a mild paroxysm large 
sinapisms over the cardiac region may be used, and even in the severest 
attacks are commonly employed along with mustard foot-baths, though 
there is no reason for believing that they affect the condition. The in- 
halation of amyl nitrite will frequently cut short an attack. Nitro- 
glycerin is equivalent to amyl nitrite, except that it is not quite so prompt 
and is more lasting in its effects. The only other effective anodyne 
remedy is morphine given hypodermically, one-fourth to one-half grain ; 
with it should be associated atropine (one-hundred-and-fiftieth to one- 
hundredth of a grain), and in cases of weak heart strychnine (one-twen- 
tieth of a grain). When the heart is extremely feeble the nitrites must 
be used with great caution, but in many cases the patient should be 
taught to carry amyl nitrite or a solution of nitroglycerin — spiritus glo- 
noini — with him, in a small vial containing a single dose, or, in the case 
of the amyl salt, in glass pearls which can be broken and their contents 
immediately inhaled. Nitroglycerin tablets also may be used. Au- 
thorities advise the administration of two or three doses of nitroglycerin 
daily as a preventive of attacks : if, however, nitroglycerin is used to ward 
off attacks it should be given not less frequently than every two hours. 

The treatment between the paroxysms should be directed against 
the underlying cardiac condition : the administration of silver nitrate, 
zinc sulphate, potassium bromide, and various other alleged nervines, as 
advised in some text-books, is the outcome of despair. 

Violent exercise, smoking, the abuse of alcohol, and all excesses 
whatever must be sedulously avoided. Emotional storms, such as a fit of 
anger or the excitement of marital or irregular coitus, have in many cases 
precipitated a fatal attack. A steep ascent, a late arrival at a railway 
train, a rush to a trolley-car, may end in sudden death. Very dangerous 
is the attempt to walk against a cold high wind, as in the case of a noted 



CARDIAC NEUROSES. 



685 



Philadelphia preacher, who, leaving his pulpit, briskly started northwest 
in the face of the wind, grasped a hand-railing, and was dead. 

In hysterical or neurasthenic pseudo-angina it is very important that 
the patient should be made to understand that the attacks are not angina. 
Hoffmann's anodyne and asafetida will sometimes suffice ; but not rarely 
morphine is imperative, notwithstanding the danger of the narcotic 
habit. Between the paroxysms the neurasthenic condition should be 
very carefully treated. 



686 



DISEASES OF THE CIRCULATORY APPARATUS. 



CHAPTEE IV. 

DISEASES OF THE ARTERIES. 
ARTERIO-SCLEROSIS. 

Definition. — An affection of the arteries characterized by circum- 
scribed or diffuse thickening of the intima and by degenerative or 
inflammatory changes in the media and sometimes in the adventitia. 

The term arterio-sclerosis was introduced by Lobstein to indicate the 
alterations frequently found in the larger arteries, especially in the aorta. 
Later, one feature of the alterations, the formation of a pap -like material, 
atheroma, was made prominent, and the entire process was designated 
atheromatous degeneration. Yirchow then applied the term endarteriitis 
chronica nodosa sive deformans to the arterial changes, but Gull and Sutton 
made it conspicuous that the analogous alterations of the blood-vessels of 
the kidney in chronic fibrous nephritis were a part of a general affection 
of the blood-vessels, to which they applied the term arterio-capillary 
fibrosis. Although at present there exists a considerable difference of 
opinion as to the unifying of all the chronic arterial changes that are 
found in advancing years under one head, the intimacy of relation 
between them is not to be denied ; they are usually regarded as manifes- 
tations of arterio-sclerosis. 

Etiology. — Evidences of arterio-sclerosis are so often found after- 
middle life that its absence in men beyond the age of fifty is exceptional. 
Its occurrence in women, however, is far less frequent. Heredity is 
generally considered as an important remote cause, although the imme- 
diate causes are far more significant. Among the latter are to be recog- 
nized over-eating, the excessive use of alcoholic drinks, lead poisoning, 
sedentary habits, repeated extreme stretching of the walls of the arteries 
in laborious occupations, and the factors of importance in the etiology of 
gout, chronic rheumatism, and diabetes. The relation between chronic 
fibrous nephritis and arterio-sclerosis admits of a threefold interpretation : 
first, that both the nephritis and the arterio-sclerosis are the results of 
the same cause ; second, that the nephritis causes a toxaemia from the in- 
sufficient elimination of the products of tissue metamorphosis, which act 
as a cause of the arterio-sclerosis ; and third, that the arterio-sclerosis 
causes the nephritis. Syphilis is the most frequent etiological factor in 
what may be called premature arterio-sclerosis, — that is, when occurring 
previous to the age of forty. Tuberculosis also is a frequent occasion of 
localized arterio-sclerosis, especially in the arteries of the pia mater, and 



DISEASES OF THE ARTERIES. 



687 



of late years etiological importance has repeatedly been assigned to acute 
infectious diseases. 

Morbid Anatomy. — The alterations occurring in arterio-sclerosis are 
either circumscribed or diffuse. The former are especially found in the 
largest arteries or in the immediate vicinity of localized lesions affecting 
the small arteries. The diffuse changes are present in both the large and 
the small arteries, and it is this variety in particular that is especially 
important in human pathology. The gross appearances of circumscribed 
arterio-sclerosis are seen to best advantage in the aorta in the condition 
called by Virchow nodular endaortitis, by Councilman nodular arterio- 
sclerosis. Circumscribed, rounded, slightly elevated, grayish- white or 
opaque white patches project from the intima, of which they represent a 
localized thickening, and increase in density and opacity in the course of 
time. The patches may be few or many, and when abundant tend to 
become confluent, thus involving a large surface. They are frequently 
found at the origin of both large and small branches of the aorta, and 
often produce narrowing of the orifices, especially of the coronary, renal, 
intercostal, and lumbar arteries. These patches, the arteriosclerotic 
plates or nodules, are due to a proliferation of the cells of the intima, the 
result, according to Virchow, of an inflammation of the deeper layers, 
but, as held by Koster, of a primary inflammatory process proceeding 
from the vasa vasorum of the media and adventitia. Thoma considers 
that the weakness of the middle coat which is so marked a feature in this 
disease is rather a cause than a result, and that the wall yields first, thus 
leaving a space, occupied in the distended condition of the artery by the 
sclerotic plates. The latter thus represent a compensatory hypertrophy 
of the intima serving to retain the normal calibre of the vessel to a greater 
or less degree. 

These " pseudo- cartilaginous plates" undergo retrograde changes, 
being transformed sometimes into atheromatous patches, abscesses, and 
ulcers, at other times into calcareous plates. A necrosis of the cells, at 
first in the deeper layers of the thickened intima, takes place, and there 
results a granular detritus of an opaque yellow color and of soft pap-like 
consistency in which fat- drops and crystals of cholesterin are found com- 
posing the atheromatous material. If the degenerative changes extend 
to the surface, the superficial layer of endothelium gives way, and the 
blood-current removes more or less of the atheromatous material from the 
cavity, the wall of which not infrequently serves as a place of origin for 
thrombi. The deposition of lime salts frequently takes place both in the 
arteriosclerotic patch and in the necrotic tissue. Thus are produced the 
osteoid plates, the surface of which is smooth towards the arterial canal, 
rough, perhaps jagged, towards the middle coat. Usually these various 
manifestations of the arterio sclerotic process are combined, and are 
associated with such loss of elasticity of the middle coat that the aorta 
is dilated and in extreme instances somewhat convoluted. 



688 



DISEASES OF THE CIRCULATORY APPARATUS. 



In diffuse arterio-sclerosis the alterations of the larger vessels are es- 
sentially the same as those already described, — namely, cellular hyper- 
plasia of the intima and degenerative changes with loss of elasticity and 
contractility in the media, the tendency being rather to extensive altera- 
tions of the wall than to circumscribed lesions. More important is the 
occurrence of an endarteritis in the smaller arteries, especially in those of 
the brain, heart, and kidneys. Councilman states that it is present also 
in the liver, in consequence of which a marked increase in density re- 
sults. A like alteration of the blood-vessels in the brain was first de- 
scribed by Friedlander as an obliterative endarteritis, and was attributed 
by him to syphilis, but similar changes are to be found there and else- 
where in consequence of tuberculosis, and in connection with fibrous 
tissue formation from various causes, notably in the so-called organization 
of a thrombus. The more extensive this diffuse endarteritis the greater 
the destruction of the organ especially affected ; but the question still 
remains open whether parenchymatous destruction precedes and causes 
or follows and results from the arterial changes. In diffuse endarteritis 
necrosis and calcification in the thickened intima do not occur in the 
smaller vessels, but are limited to arteries of the size of the radial. 

There exists a considerable difference of opinion as to the relation 
between tortuous arteries and those altered in consequence of arterio- 
sclerosis. The splenic artery, the iliac artery, and others as small as 
the temporal arteries, not infrequently become elongated and varicose in 
advancing years, the serpentine aneurism ; but such abnormality of the 
visible external arteries is no evidence of the existence of arterio-sclerosis 
of the aorta or of its branches. In the larger arteries a deposition of lime 
salts often occurs in the muscular media, in consequence of which it be- 
comes transversely ribbed. A similar infiltration of lime salts may take 
place in the arteries of the extremities, transforming them into rigid tubes, 
often compared to pipe-stems. Such changes are generally considered as 
degenerative, and in no way necessarily connected with the proliferative 
changes in arterio-sclerosis. They may be combined with the latter, how- 
ever, and the tortuous splenic artery may show circumscribed sacculated 
dilatations due to endarteritis^ the dilated portions being diffusely infil- 
trated with lime salts as in the case of the calcified plates of the aorta. 
In arterio-sclerosis, especially of the coronary arteries of the heart and of 
the arteries of the extremities, the secondary deposition of lime salts may 
cause rigid tubes as in calcification of the media, but the earthy salts 
are deposited rather in the intima than in the middle coat. 

Hypertrophy of the heart, especially of the left ventricle, is constantly 
associated with arterio-sclerosis. Some pathologists believe that the loss 
of arterial elasticity and contractility calls for increased work on the part 
of the heart to drive the blood to the periphery of the body ; others think 
that a primary hypertrophy of the heart causes stretching and weaken- 
ing of the media and thickening of the intima, tending to restore the 



DISEASES OF THE ARTERIES. 



689 



previous calibre of the artery. The appearances of the heart are those 
either of idiopathic hypertrophy or, in case there is sclerosis of the coro- 
nary arteries, of hypertrophy combined with fibrous myocarditis and 
with dilatation. Indeed, as already stated, the common cause of fibrous 
myocarditis is sclerosis of the coronary arteries. 

Symptoms. —Nodular arterio-sclerosis of the aorta is not usually pro- 
ductive of symptoms. Sometimes the dilatation of the arch is sufficient 
to be manifested by an increased area of dulness at the right and upper 
portion of the sternum and by visible or palpable pulsation at the sternal 
notch. In such cases an inequality of the pulses recognizable at the 
wist may be due to the narrowing of the orifice of an innominate artery. 
It is also possible that the muscular pains and weakness of the trunk so 
often complained of by elderly people may be the result of interference 
with the circulation through the intercostal and lumbar arteries in con- 
sequence of a narrowing of their orifices by sclerotic patches. If the 
sclerotic plates are situated at the origin of the coronary or renal arteries 
the nutrition of the heart or of the kidneys is likely to be disturbed, 
and brown atrophy of the heart or simple atrophy of the kidney result. 
The slowly progressing enfeeblement of the heart, the transitory and 
slight albuminuria, even when associated with an occasional hyaline cast, 
in old people, thus meet with a satisfactory explanation. 

Diffuse arterio-sclerosis not only causes hypertrophy of the heart to 
overcome the obstruction, but also interferes with the nutrition of the 
organs especially concerned. The gradual progress of the cardiac hyper- 
trophy is compensatory, and symptoms of arterio-sclerosis are unlikely 
to arise until the heart presents signs of failing compensation or localizing 
symptoms call attention to the brain or kidneys. During this period of 
progressing arterio-sclerosis the signs of cardiac hypertrophy are present, 
— namely, downward and outward displacement and abnormally power- 
ful beat of the apex, accentuation of the second aortic sound, and a pulse 
of high tension, full, regular, and sometimes slow. The especial charac- 
teristic is the cord-like feel of the radial artery when under considerable 
pressure of the finger, a sign not to be confounded with the extreme 
rigidity indicative of calcification, which is characteristic rather of senile 
and degenerative changes than of the productive as well as degenerative 
lesions of arterio-sclerosis. A tortuous course of the radial artery, un- 
less associated with a pulse of high tension, is not a necessary indication 
of diffuse arterio-sclerosis. As the hypertrophied heart weakens, the 
tension of the pulse may be lowered, and cough and shortness of breath 
result from the weakened heart not being able to overcome the obstruc- 
tion to the flow of blood. Diffuse arterio-sclerosis of the coronary arte- 
ries of the heart produces myomalacia and fibrous myocarditis, manifested 
by precordial discomfort, perhaps ending in attacks of angina pectoris, 
in dyspnoea, which may be asthmatic or may present the Cheyne-Stokes 
characteristics, and, eventually, in acute cedenia of the lungs. Arterio- 

44 



690 



DISEASES OF THE CIRCULATORY APPARATUS. 



sclerosis of the cerebral vessels is indicated by preliminary attacks of 
headache or dizziness, perhaps followed by evidence of cerebral hemor- 
rhage or of cerebral softening. Even temporary attacks of localized dis- 
turbance of cerebral function may occur in arterio-sclerosis, especially 
when the latter is dependent upon syphilis or associated with nephritis. 
If the arterio-sclerosis occurs predominantly in the kidney, the symptoms 
are those of a slowly progressing fibrous nephritis ; slight attacks of dys- 
pnoea, indigestion, headache, muscular weakness, disturbance of vision, 
frequency of micturition, and thirst give evidence that the renal arterio- 
sclerosis has occasioned such destruction of tissue that a state of renal 
inadequacy exists. Arterio-sclerosis of the vessels of the extremities is 
less a cause of gangrene than is calcification of the muscular media. 
Senile gangrene when not of embolic nature is to be regarded as due 
rather to arterial calcification than to arterio-sclerosis, while diabetic 
gangrene may be the result of the obliterating tendency of arterio-sclerosis. 

Diagnosis. — The presence of nodular arterio-sclerosis is to be assumed 
in elderly people, though sometimes it is absent in them. Incipient dif- 
fuse arterio-sclerosis is to be suspected from a pulse of persistent high 
tension, and its presence is to be considered probable when the signs of 
idiopathic hypertrophy of the heart are also present. The diagnosis of 
a sclerosis of the coronary arteries of the heart is essentially that of a 
fibrous myocarditis, and the renal arteries are to be considered sclerotic 
when there is evidence of a chronic fibrous nephritis. The diagnosis of 
cerebral arterio-sclerosis is based upon the association of symptoms of 
disturbed cerebral circulation with evidence of arterio-sclerosis elsewhere 
in the body. 

Prognosis. — The prognosis of general arterio-sclerosis is always un- 
certain, though not necessarily grave. It is uncertain, since rupture of 
the diseased arteries or aneurisms may ensue. It becomes grave when 
there is a conspicuous affection of the blood-vessels of the heart or of the 
kidneys. 

Treatment. — Although potassium iodide is recommended by some 
good observers in arterio-sclerosis, we do not believe that the condition is 
amenable to treatment ; in the early stages much can be done to arrest the 
development of the disease by removal of its cause. Thus, if alcohol, 
lead, or other poison be producing the disease, the treatment should be 
that of the chronic poisoning ; if the subject be syphilitic, continuous mild 
antisyphilitic treatment should be employed ; if there be a gouty diath- 
esis, this should be actively combated ; if there be renal disease, efforts 
must be directed to overcoming its effects ; if, as in many cases, the source 
of the trouble be over- eating, especially of rich nitrogenous food, with 
under-exercising, the life-habits should be changed. Very often it is 
necessary to explain to the patient the condition, so that by a quiet, 
abstemious life, with abundance of gentle and continuous out- door exer- 
cise, the degeneration of the arteries may be delayed. In many cases. 



DISEASES OF THE ARTERIES. 



691 



especially when the habits of the patient cannot be thoroughly controlled, 
life will be prolonged and made more comfortable by yearly visits to 
alkaline purgative mineral springs, — a custom which often may be con- 
tinued with advantage even in the advanced stages of the disorder. Not 
rarely the habitual use of the Turkish bath does good by maintaining the 
activity of the skin. In the advanced stages of the disorder, however, 
great care must be taken in exposing patients to high heat, especially if 
there be any secondary cardiac involvement. 

As it is impossible to change arteries which have undergone degener- 
ation, the treatment in the advanced stages of arterio-sclerosis is chiefly 
directed to combating the symptoms of various local disorders as they 
arise. In apoplectic attacks, with arterial tension, lividity of the face, 
or marked dyspnoea, venesection may be sometimes necessary for tempo- 
rary relief. 

ANEURISM. 

Definition. — The localized dilatation of an artery. 

Varieties. — In true aneurism all the coats of the artery are present 
at the outset, although at a later stage it may be impossible to differ- 
entiate them. In false aneurism the tissues surrounding the artery are 
pushed aside by blood which has escaped from a torn or cut artery. The 
dissecting aneurism of the aorta is usually regarded as a variety of false 
aneurism, since at no time are all the coats of the artery contained in 
the wall. It is the result of a tear into the weakened media through the 
altered intima in arterio-sclerosis, and the layers of the middle coat are 
split apart by the force of the blood- current. 

When an artery communicates directly with a vein, the resulting 
dilatation of the vessels is called aneurism by anastomosis. If a true 
aneurism communicates with a vein, the term arterio-venous aneurism is 
applied ; while if the communication is established through a false 
aneurism, the condition is known as varicose aneurism. 

Etiology. — Aneurisms occur at all periods of life, but especially 
during the middle third, and more often in men than in women. The 
essential cause is a diminished resistance of the wall, which may be ac- 
companied by an increased blood-pressure. The diminished resistance of 
the wall is largely due to premature arterio-sclerosis : hence the impor- 
tance of syphilis, and perhaps of alcoholic abuse, in the etiology of aneu- 
risms. It should be mentioned that aneurisms may occur without the 
physical signs of arterio-sclerosis : hence it is assumed that a weakening 
of the coat represents an early stage of arterio-sclerosis. The wall may 
be weakened in consequence of the production of an acute endarteritis by 
an infectious thrombus or embolus, or may be torn by a calcified embolus. 

The importance of increased blood -pressure is suggested by the rela- 
tive frequency of aneurisms among persons exposed to laborious muscular 
work or severe muscular strain, as sailors and blacksmiths. Evidence 
in the same direction is presented by the more frequent occurrence of 



692 



DISEASES OF THE CIRCULATORY APPARATUS. 



aneurisms of the aorta at its arch, and by the frequent projection of 
sacculated aneurisms from those points in serpentine aneurism of the 
splenic artery at which the direction of the current of blood is abruptly 
changed. Violence is also of importance in etiology, especially in aneu- 
risms of the peripheral arteries. A variety of aneurism of rare occur- 
rence and of unknown etiology has been described by Kussmaul and 
Maier under the term nodular periarteritis. In this affection the intima is 
forced through a ruptured media, local swellings of the adventitia follow, 
and thus multiple aneurisms are rapidly produced along the course of the 
smaller arteries of the body. 

Morbid Anatomy. — The dilatation of the artery is either circum- 
scribed or diffuse. The circumscribed dilatation is cylindrical, spindle- 
shaped, or globular : hence cylindrical, fusiform, and sacculated aneurisms 
are discriminated. One or many aneurisms, in rare instances a hundred 
or more, may be present, varying in size from those not larger than a 
grain of sand, the miliary aneurisms of the brain, to those which are as 
large as an infant's head. Diffuse dilatation affects an artery and per- 
haps its branches over a considerable distance ; in consequence of the tor- 
tuous course pursued, this variety is called cirsoid or serpentine aneurism. 

At the outset the wall is composed of the three coats of the artery, 
but as the aneurism increases in size the middle coat disappears, the 
outer and inner coats become fused, and only a single layer of fibrous 
tissue remains. Where the three coats are to be differentiated, the ap- 
pearances of art erio- sclerosis are likely to be found in the intima ; fissures, 
fat-drops, leukocytic infiltration, or fibrous scars are present in the middle 
coat, and the adventitia is abundantly infiltrated with cells. The cir- 
cumscribed aneurism communicates with the artery from which it arises 
by a large or a small opening, which is round or slit-like, and usually 
contains a lamellated thrombus which sometimes completely fills the sac. 
The oldest portions of the thrombus, lying upon the wall, are brittle, of 
an opaque yellowish -gray color, and are covered by elastic layers of a 
translucent pale-red tint, while the free surface is dark red, and often 
ribbed. As the aneurism increases in size, displacement of neighboring 
structures takes place when possible, compression is exercised upon yield- 
ing structures, and resistant tissues, especially bone, are eroded and ab- 
sorbed. The orifices of arterial branches arising in the vicinity of the 
aneurism may be distorted, and the branches, after being stretched or 
compressed, may become obliterated. Thrombi frequently are formed in 
veins which are compressed by the aneurism. 

Symptoms. — The symptoms of aneurism depend largely upon the 
size and situation of the dilatation, and in certain cases there may be 
no symptoms. In general, the disturbances produced are the result of 
pressure or of rupture, although the aneurism may first become apparent 
as a pulsating tumor. Miliary aneurisms of the brain are usually unsus- 
pected until rupture occurs, followed by cerebral hemorrhage. 



DISEASES OF THE ARTERIES. 



693 



ANEURISM OF THE AORTA. 

The aorta from its origin to its bifurcation is a frequent seat of 
aneurisms, which are usually divided into thoracic and abdominal aneu- 
risms according to the region concerned. Aneurism is oftenest found at 
the arch of the aorta, and in that locality, when large, forms a pulsating 
tumor pressing upon the structures in its vicinity, the symptoms vary- 
ing according to the part of the arch especially affected. 

Aneurism of the ascending portiou of the arch may project into the 
pericardial cavity and produce no symptoms until rupture takes place, 
when immediate death results from hemorrhage into the pericardium. 
Aneurisms in this region also cause dilatation of the aortic orifice or 
shrinkage of the aortic valves, and thus, unless a considerable tumor 
is formed, give rise only to the signs and symptoms of aortic insuf- 
ficiency. As the tumor increases in size it is likely to occasion local pain, 
which is due to pressure upon the cardiac plexus of nerves or upon those 
of the pleura, pericardium, or skin. The pain, therefore, varies in 
character, being either anginoid, stitch-like, aching, or neuralgic, and is 
occasional, paroxysmal, or persistent. Pressure upon the superior vena 
cava results in venous congestion of the head, neck, and arms, or an 
innominate vein, usually the right, may be conspicuously compressed, 
with a corresponding limitation of the cyanosis and oedema to one side or 
to the other. Perforation of the superior vena cava sometimes occurs, 
and Pepper and Griffith have called attention to the importance of the 
sudden development of cyanosis and oedema as indicating this complica- 
tion. Pressure upon the azygos vein may also take place, giving rise to 
hydrothorax. Pressure upon the neighboring sympathetic causes dilata- 
tion or contraction of the pupil of the right eye according as irritation or 
paralysis of the sympathetic fibres takes place. The right vocal cord is 
sometimes paralyzed from pressure upon the recurrent laryngeal nerve. 

Aneurism of the transverse portion of the arch has a wider range of 
pressure-symptoms, since the respiratory and digestive tracts are con- 
cerned, as well as the blood-vessels and the nerves. Pressure upon the 
trachea causes dyspnoea, the breathing at times having a stridulous sound 
or presenting an asthmatic or a Cheyne- Stokes character. There is not 
iiifrequently cough from the catarrhal inflammation of the trachea and 
bronchi, and a considerable quantity of secretion, at times blood-stained 
from congestion of the mucous membrane, may be expectorated. Pressure 
upon a primary bronchus is also productive of cough and dyspnoea asso- 
ciated with feeble respiratory sounds in the part of the lung affected, and 
may lead to retention of secretion in the bronchi, with resulting putrefac- 
tion, ending in gangrene and abscess of the lung. The left vocal cord is 
frequently paralyzed from pressure upon the left recurrent laryngeal nerve 
in its course around the arch, and hoarseness, or aphonia, and paroxysms 
of suffocation may ensue. Pressure upon the pneumogastric nerve is 



694 



DISEASES OF THE CIRCULATORY APPARATUS. 



rare, but sometimes happens, causing vomiting and spasm of the oesopha- 
gus, with difficulty in swallowing. When the oesophagus is compressed, 
persistent difficulty of swallowing, especially of solid food, occurs, and 
the possibility of the presence of an aneurism as the cause of a dys- 
phagia should be eliminated before the use of a sound, since the latter 
has caused immediate death by perforating an aneurism compressing the 
oesophagus. The emaciation resulting from aneurismal obstruction of 
the oesophagus may in rare cases be enhanced by the pressure of the 
aneurism upon the thoracic duct. The left innominate vein is especially 
liable to compression, in which case oedema of the left half of the head 
and neck and of the left arm follows. The orifice of the innominate, 
the left carotid, or the left subclavian artery, especially of the innominate 
artery, may be dilated and form part of the aneurism ; on the other 
hand, these vessels are likely, also, to become narrowed and distorted, 
perhaps obliterated, and may be compressed or obstructed by thrombi. 
Corresponding variations in the character of the pulsations in them 
result, especially noticeable in the marked differences sometimes recog- 
nized in the radial pulses. The pulmonary artery has been compressed, 
causing compensatory hypertrophy of the right ventricle, and in rare 
instances this artery has been even perforated. 

Pain is more characteristic of aneurism of the descending portion 
of the arch and of the thoracic aorta than are symptoms of pressure, 
although the oesophagus, trachea, left bronchus, and lung may be com- 
pressed, and dysphagia, dyspnoea, and cough result. The pain is usually 
attributed to erosion of the vertebrae, although it is more probably occa- 
sioned by a neuritis developed as the spinal nerves become incorporated 
in the walls of the sac : it is generally referred to the back, in the 
region of the left scapula. The spinal cord in rare instances has been 
exposed and compressed, with the production of paralysis. Flint men- 
tions that aneurism of the descending aorta causes a delay in the pulsa- 
tions in the arteries of the lower extremities as compared with the radial 
pulse, and Osier states that the femoral pulse may be absent although 
the blood is distributed to the vessels of the leg. 

The physical examination of the thoracic aorta in case of suspected 
aneurism seeks to establish the presence of a pulsating tumor. When 
the aneurism is small, or the chest- wall does not yield to its growth, there 
is no visible tumor. An abnormal area of dulness may be appreciated 
either at the right or across the upper part of the sternum. If the 
ascending or the transverse portion of the arch is enlarged, the dulness 
may be recognized also at the left of the spine in case the descending 
portion of the arch and the continuous portions of the thoracic aorta are 
concerned. Eventually the aneurism may so increase in size as to pro- 
duce a visible pulsatory heaving of the chest- wall near the second and 
third right costal cartilages, at the sternal notch, or near the spine, accord- 
ing to the seat of the aneurism, and the larger the tumor the more likely 



DISEASES OF THE ARTERIES. 



695 



is there to be a displacement of the heart downward and to the left. If 
the sternum becomes eroded, a tumor with expansile and often powerful 
pulsation projects in the region of the manubrium and extends consider- 
ably beyond its borders. The overlying skin eventually becomes livid 
and necrotic at the place of greatest tension. The tumor is resistant 
when it contains abundant clotted blood, though readily yielding to 
pressure when the contents are largely liquid. A systolic thrill as well 
as a powerful systolic impulse is at times to be felt, and a feeble dias- 
tolic beat is not infrequently perceptible. Oliver, Eoss, and others have 
emphasized the value of tracheal tugging as a sign of deep-seated aortic 
aneurism, and it has been asserted that it is never present except when 
there is an aneurism. According to Grimsdale, however, this sign is of 
little positive value, since he found it in sixteen per cent, of a number 
of persons free from aneurism and examined with reference to its pres- 
ence. The tugging is attributed to the direct pressure during cardiac 
systole of the dilated artery upon the left bronchus, or upon the por- 
tion of the trachea immediately adjoining. The sensation is to be ob- 
tained by gently pressing the fingers or thumbs against the cricoid car- 
tilage from below upward while standing either in front of or behind 
the patient. On auscultation over the aneurism two sounds are usually 
distinctly heard, one resulting from the distention of the aneurism, the 
other due to the transmission of the second cardiac sound when the aortic 
valves are sufficient. There may be no murmurs, or a systolic murmur 
is to be heard, which is usually of little diagnostic importance unless com- 
bined with a diastolic murmur. The latter is indicative of an associated 
aortic incompetence, but may be produced by an eddy in the aneurism. 

In the further progress of aortic aneurism the tendency is towards 
increased disturbance of respiration, perhaps associated with fever, pro- 
gressive loss of flesh and strength, and hemorrhage. The bleeding is 
often the immediate cause of death, and may take place externally or 
internally. In the former case blood is poured from the mouth by way 
of the oesophagus, trachea, or lungs, or escapes through the skin. Per- 
foration internally takes place into the pericardial or the pleural cavity, 
perhaps into the stomach through the oesophagus. The immediately 
fatal hemorrhage may be preceded by occasional gushes or by slight 
oozing, separated by intervals of days or weeks. Embolism is an occa- 
sional complication, resulting from detachment of portions of the con- 
tained thrombus and their transfer into one of the branches of the aorta. 

Diagnosis. — The suspicion of an aneurism may be based upon the 
physical signs or upon the symptoms, but the diagnosis usually requires 
the presence of both physical and rational signs, and may then be doubt- 
ful. An expansile pulsating tumor is not always present, and the ex- 
pansile pulsation of an unusually high aortic arch or that transmitted 
from an hypertrophied and dilated heart may be mistaken for the pulsa- 
tion of an aneurism. The former produces no pressure- symptoms, and 



696 



DISEASES OF THE CIRCULATORY APPARATUS. 



the latter is accompanied usually by the signs of aortic insufficiency. 
A solid tumor of the mediastinum or one at the base of the neck may 
transmit pulsations, but undergoes no corresponding change of volume. 
The former muffles the heart-sounds, although interfering but little with 
breathing and swallowing. Both compress adjacent veins, although 
affecting the arteries but little. 

Prognosis. — Aneurisms of the arch and of the thoracic aorta are 
always a source of danger, and usually prove fatal, although they may 
exist for years. Their progress may be checked for a long time by the 
formation of thrombi, but the process of repair is always incomplete, and 
it is doubtful if any true aneurism of the arch large enough to produce 
symptoms has ever been healed. 

ANEURISM OF THE ABDOMINAL AORTA. 

Aneurism of the abdominal aorta attaining any considerable size 
usually begins in the vicinity of the cceliac axis, which is often incor- 
porated in the sac. The tumor may be large and prevent the descent 
of the diaphragm. The lumbar vertebrae are frequently eroded, and 
then form the posterior wall of the aneurism, being covered merely 
by a lamellated thrombus. The chief symptom is pain, perhaps fol- 
lowed by numbness, due to pressure upon neighboring nerves or their 
incorporation in the wall of the tumor. As in thoracic aneurism, the 
pain may be referred to the back, although the hand of the patient when 
indicating its seat at times points to the front. There is usually fixed 
pain in the epigastric region, but shooting pains often follow the lumbar 
or sciatic nerve. Symptoms of pressure are less significant than in 
aneurism of the thoracic aorta. Vomiting results from pressure on the 
pylorus or the duodenum, and pressure upon the colon may interfere 
with the action of the bowel. Aneurism of the abdominal aorta when 
sufficiently large to produce symptoms usually continues to increase in 
size, perhaps with periods of temporary quiescence, until rupture of the 
wall occurs. Fatal perforation then takes place into the alimentary canal 
or into the peritoneal or the pleural cavity. The immediately fatal hem- 
orrhage is sometimes preceded by the escape of blood into the retroperi- 
toneal tissues, especially at the left of the spine, causing a rapid increase 
in the size of the tumor, associated with pain, and suggesting a localized 
peritonitis. In rare instances the erosion of the vertebrae is so extreme 
as to lead to compression of the spinal cord and paralysis. Sometimes 
the superior mesenteric artery is obstructed by embolism or continued 
thrombosis from the aneurism, acute hemorrhagic infarction of the in- 
testine being the result. The renal arteries, and those of the legs also, 
may be the seat of the embolism. 

Diagnosis. — The diagnosis of this variety of aortic aneurism depends 
upon the recognition of an immovable rounded or elongated tumor which 
has an expansile pulsation and may transmit a thrill. On auscultation 



DISEASES OF THE ARTERIES. 



697 



a systolic, perhaps a double, murmur is to be heard. The femoral as com- 
pared with the radial pulse is delayed. The pulsation of the aneurismal 
tumor may be simulated by the energetic beating of the aorta in neuras- 
thenic, anseniic, or emaciated persons, especially in hysterical women, or 
by the powerful impulse of the aorta in hypertrophy and dilatation of 
the left ventricle. The characteristics of the patient, the absence of pain, 
and the paroxysmal nature of the throbbing indicate the functional dis- 
turbance, while the physical examination of the heart makes clear its 
hypertrophy. Tumors of the stomach, of the liver, or of the head of 
the pancreas not infrequently transmit the aortic impulse. They are to 
be excluded by frequent mobility and by a disappearance of the pulsa- 
tion when the patient is placed in the knee-elbow position. 

Aneurisms of the cceliac axis and of its branches, the mesenteric, 
renal, and iliac arteries, also occur, but are not to be recognized unless 
forming a pulsating tumor. It is to be remembered, however, that the 
rupture of abdominal aneurism is one of the causes of intra-abdominal, 
perhaps of intra-peritoneal, hemorrhage, to be relieved only by surgical 
treatment. 

Prognosis. — The prognosis of this variety of aortic aneurism is ex- 
ceedingly grave, death usually resulting from perforation and hemor- 
rhage. 

Treatment of Aneurism. — Measures for the cure of aneurism have 
for their object the obliteration of the sac or more usually of the entire 
lumen of the affected artery, and are mechanical (that is, surgical) in 
their nature. The most effective of these surgical procedures, such as 
ligation or arrest of circulation for a series of hours by pressure on the 
artery above the aneurism so as to bring on coagulation within the artery, 
are plainly not applicable to aneurism of the aorta. In a number of cases, 
however, the carotid, the subclavian, or both vessels, have been tied for 
aneurism of the aortic arch. Sometimes prolonged relief of the symp- 
toms has been obtained ; usually the operation has been without avail : it 
would seem to be justifiable only when the arteries tied have their aortic 
origins involved in the aneurism. A second mechanical method which 
has been used in a number of cases consists in putting into the aneurism 
horse-hair, fine wire, or a similar foreign body, which shall mechanically 
bring about a coagulation of the blood within the sac. Again, combined 
with the use of such materials has been the injection of a few drops of a 
strong coagulating solution, such as liquor ferri perchloridi. Attempts 
have also been made to secure coagulation by electrolysis, and it has 
been asserted that the use of fine silver wire inserted through the hy- 
podermic needle into the sac, associated with subsequent electrolysis 
(Loreta's method), is sometimes successful. Almost always, however, 
the induction of these foreign materials into an aortic aneurism has 
proved disastrous to the patient ; nor has any better result attended per- 
sistent compression by means of the pad. When the aneurism pro- 



698 



DISEASES OF THE CIRCULATORY APPARATUS. 



trades through the chest-wall an elastic mechanical support may be used ; 
but permanent compression by an inelastic pad can rarely be borne, and 
still more rarely does it do good. 

In the great majority of cases we are forced to rely upon medical 
treatment in aortic aneurism, though such treatment seldom if ever suf- 
fices for a cure. The object of the treatment is to bring about coagula- 
tion in the sac by reducing the force of the blood- current and increasing 
the coagulability of the blood. The classical method seems to have 
been first systematized by Valsalva, though perfected and exploited by 
Joliffe Tufnell; it consists in prolonged absolute rest in the recumbent 
position, with a restriction of food, and especially of drink, nearly to 
the minimum necessary for the sustaining of life, and the use of cardiac 
sedatives ; to it may be added various narcotics for the relief of pain 
and restlessness, and in robust cases even venesection. In order to be 
effective the rest must be absolute. Two diets are employed : one, 
known as the "low," consists daily of ten ounces of bread, six ounces of 
farinaceous pudding, one ounce of butter, and one pint of milk, divided 
into three meals ; fish or boiled meat being added from time to time, if 
the diet be insupportable by the patient. The u dry" diet consists of four 
ounces of bread, one-half ounce of butter, and two ounces of milk, for 
both breakfast and supper, and three ounces each of meat and bread 
and one ounce of milk for dinner. Many authorities advise repeated 
venesection. 

Theoretically the Valsalva treatment should be continued for from 
three to four months; practically very few patients can be found to 
tolerate it for more than six or eight weeks ; often the best that can be 
done is to give from time to time short courses of the treatment. In all 
cases the return to the normal diet should be gradual. The Valsalva 
method of treatment is very irksome, and the result is so uncertain that 
patients may rationally prefer a quicker death to prolonged discomfort. 
When there is any evidence that the aneurismal sac has a wide mouth, 
or when the aneurism is fusiform in character, the chances of a good 
result are greatly lessened. To our thinking, the wisest thing to do 
in most cases of aortic aneurism is to make the patient comfortable as 
long as possible, and not to trouble him and his friends with unavailing 
restrictions. 

Potassium iodide is a valuable remedy in the treatment of aortic aneu- 
rism, even when there is no distinct syphilitic history. How it acts is not 
known ; it appears often to bring about relief of pain and greatly to 
favor coagulation of the blood in the sac : ten to fifteen grains three times 
a day may be given continuously. The only drug which should be used 
to reduce heart- action is aconite. Veratrum viride is less effective unless 
given in large dose, and then it is apt to produce vomiting. The bro- 
mides, opium, and other narcotics may be administered for the benumb- 
ing of the nervous system and the obtaining of sleep. Digitalis, which 



DISEASES OF THE ARTERIES. 



699 



has been much used by certain surgeons in the treatment of aneurisms, is 
an especially dangerous remedy. The survival of many patients who have 
taken it has been due to the drug having been given in such small doses 
as to be ineffectual : given in large doses it increases not only the force 
of the circulation, but also the size of the pulse- wave, and thus greatly 
endangers the tearing away of fibrinous coagula or the rupturing of the 
sac itself. We have seen the enormous blood- wave produced by digitalis 
tear open an aortic aneurism, with immediately fatal results. 

Under any circumstances the patient with aneurism should lead a 
quiet life, avoiding emotional and muscular excitement, but not, unless 
forced by suffering, putting aside all mental work. 

The chief aneurismal symptoms requiring treatment are those which 
are produced by pressure : there is nothing that will relieve the pain 
caused by an eroding aneurism but morphine. Intense engorgement of 
the venous system of the head and arms, and violent attacks of dyspnoea 
with cyanosis, sometimes may require free venesection for relief. Dys- 
pnoea due to pressure upon the trachea is usually the outcome of com- 
pression near the bifurcation, and is not to be relieved by tracheotomy : 
in those rare cases in which bilateral abductor paralysis is caused by 
pressure on the recurrent laryngeal nerves, as revealed by laryngoscopic 
examination, tracheotomy may bring relief. 



SECTION IV. 

DISEASES OF THE RESPIRATORY APPARATUS. 



CHAPTER I. 

DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 

DISEASES OF THE NOSE. 
EPISTAXIS. NOSEBLEED. 

Bleeding from the nose is the result of injury either from without, as 
a blow, or from within in consequence of picking the nose, or of impaction 
of foreign bodies, or of a fracture at the base of the skull. Local affec- 
tions of the nasal mucous membrane, as inflammation, ulcer, and polypi, 
act as causes. Diseases of the blood-vessels, especially dilatation of the 
veins, and hypertrophy of the heart connected with arterio -sclerosis, are, 
at times, productive of nosebleed. Epistaxis is infrequent, however, in 
the chronic venous congestion associated with obstruction to the circula- 
tion from chronic disease of the heart and lungs. The ascent into rarefied 
air, as in mountain- climbing or in a balloon, produces nosebleed. It is 
of occasional occurrence in young women during menstruation, and its 
presence, especially periodically, when the catamenia are absent is re- 
garded as a vicarious menstruation. Nosebleed is of frequent occurrence 
at the outset of typhoid fever, and may occur in the early stage of other 
infectious diseases. It is of frequent occurrence in chronic anaemia, in 
leukaemia, in hemorrhagic diathesis, and in haemophilia. Plethoric persons 
not infrequently suffer from nosebleed, but the popular assumption that 
frequent nosebleed is a forerunner of cerebral hemorrhage lacks satis- 
factory proof. 

Bleeding independent of local causes takes place as an oozing, usually 
from the anterior and lower portion of the cartilaginous septum from one 
nostril, sometimes from both nostrils. Commonly the blood flows drop 
by drop from the nasal opening, although it occasionally forms a con- 
tinuous stream of considerable size, or may be manifested by a pro- 
jecting clot. The blood may pass into the pharynx, and, when coughed 
out or swallowed and vomited, be thought to originate in the lungs or 
700 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 701 

stomach. Attacks of nosebleed are rarely sufficient to produce more 
than temporary weakness. Frequently recurring attacks of epistaxis, 
however, may result in the symptoms of anaemia, and always demand the 
search for a local cause in the nostril. Nasal hemorrhage from fracture 
at the base of the skull may prove a cause of death. 

Treatment. — In many cases epistaxis can be controlled by simple 
procedures habitually employed in the household, such as holding the 
hands up, applying ice or cold pieces of metal to the back of the neck 
or to the nose, or snuffing up very cold or, preferably, very hot water. 
The application of a saturated solution of antipyrin or a ten per cent, 
solution of cocaine is sometimes useful, or solutions of astringents, such 
as tannic acid or alum, may be injected. Pressure may be applied upon 
the facial artery as it passes over the lower jaw. The late D. Hayes 
Agnew stated that he had frequently arrested violent epistaxis, even in 
cases in which plugging the posterior nares had been insufficient, by 
making a bougie of a long strip of the rind of bacon, passing it through 
the nostril, and allowing it to stay there some time. When the epistaxis 
comes from an ulcerated point that can be reached, the local application 
of solution of chromic acid or of solid silver nitrate should be made. 
In any case, if the hemorrhage continues in spite of milder measures, the 
nares should be plugged both posteriorly and anteriorly. 

ACUTE RHINITIS. ACUTE NASAL CATARRH. CORYZA. COLD IN 

THE HEAD. 

Etiology. — Acute rhinitis is often the result of exposure to draughts 
of air, to cold or wet weather, and to the local action of inhaled irritants, 
as dust of various sorts, gas, vapor, or steam. The irritation from bac- 
teria is probably important, as is suggested by the occurrence of epi- 
demics of acute nasal catarrh ; indeed, it is not unlikely that 1 i taking 
cold" from exposure to cold and damp is due to bacterial action, the 
growth of the bacteria being favored by the circulatory disturbance in 
the nostrils produced by the exposure. The importance of infection in 
etiology is also suggested by the occurrence of acute rhinitis as an early 
manifestation of measles, influenza, and diphtheria ; and gonococcal and 
syphilitic infections may be followed also by acute rhinitis. Inflamma- 
tion of the nasal mucous membrane not infrequently results from the 
extension of inflammation of the continuous mucous membrane of the 
mouth and pharynx. 

Symptoms. — Frequent sneezing and increasing obstruction of the nos- 
trils are the significant symptoms of acute rhinitis. These are not infre- 
quently preceded by chilly sensations followed by slight fever, the tem- 
perature rising one or two degrees, and by a feeling of general discomfort, 
perhaps weakness. There is at first a profuse watery secretion from the 
nasal mucous membrane ; later it is slimy and finally opaque yellow. The 
sense of smell becomes impaired, if not lost, and that of taste is also en- 



702 



DISEASES OF THE RESPIRATORY APPARATUS. 



feebled. Herpes of the nostrils or upper lip is not infrequent, and the 
constant flow of the nasal discharge often causes a maceration of the 
epidermis, resulting in abrasions upon which crusts finally are formed. 
The mucous membrane is swollen, reddened, and covered with more 
or less opaque mucus. Towards the end of the attack it may be eroded 
and coated or encrusted with pus. Extension of the inflammation to 
the conjunctiva is frequent, causing redness, swelling, abundant lach- 
rymation, and excessive secretion, and this often dries at the inner 
canthi. Severe headache and frontal neuralgia follow extension of the 
rhinitis to the frontal sinuses, and deafness results from a secondary in- 
flammation of the pharynx at the opening of the Eustachian tube. After 
a few days the symptoms usually disappear, with the exception of the 
discharge from the nostrils, which may continue gradually diminishing 
in quantity for a week or ten days. 

Although the diagnosis of acute rhinitis is easily made, it is to be 
remembered that the cause is usually uncertain, since various contagious 
and infectious diseases begin with nasal catarrh. Caution in diagnosis is 
especially necessary during epidemics of measles, diphtheria, and in- 
fluenza. In general acute rhinitis is unimportant, though disagreeable, 
but the possibility of its extension to the bronchi, especially in the very 
old and the very young, should be remembered, in which event the out- 
come may be uncertain. Obstruction to the nostrils so interferes with the 
nursing of infants that feeding with a spoon is often necessary. 

Treatment. — Acute coryza does not ordinarily require confinement 
to the house, but in delicate, very old, or very young subjects it may 
even be necessary to put the patient to bed. In its formation-period the 
disease can in many people be arrested or modified by a full dose of 
quinine taken at bedtime, or by camphor (twenty drops of the tincture 
every two hours). Often, especially when the attack is accompanied by 
aching pains or other evidences of a general cold, a free sweat is useful 
(see formula 7), or the Turkish bath may be tried. Local treatment 
usually gives great relief. Formula 12 may be used, or bougies made 
with cacao butter containing one-fourth to one-half of a grain of cocaine 
may be inserted into the nostrils every four to six hours. 

CHRONIC RHINITIS. CHRONIC NASAL CATARRH. 

Etiology. — Constant exposure to the causes of acute rhinitis, espe- 
cially to irritating dust, and to cold and wet in various trades or occu- 
pations, and frequently recurring or unusually severe attacks of acute 
rhinitis, are the usual causes of chronic inflammation of the nasal mucous 
membrane. Especially likely to become chronic is acute rhinitis ex- 
tended into the frontal or ethmoidal sinuses or into the antrum of High- 
more. Chronic rhinitis is frequent in scrofulous children, and im- 
portance in etiology is to be attached to the construction of the nose, 
especially to the presence of a deviated septum, which by permanently 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 703 

narrowing the passages permits the retention of inflammatory causes and 
products. 

Symptoms. — Two varieties of chronic rhinitis are recognized, the 
hypertrophic and the atrophic, according to the nature of the predomi- 
nant changes of the mucous membrane, but hypertrophy and atrophy are 
frequently combined. In hypertrophic rhinitis the nasal mucous mem- 
brane is reddened and swollen, often to such an extent that the space 
between the nasal septum and the turbinated bones is obliterated. The 
swelling of the mucous membrane may be general or limited to the an- 
terior or to the posterior nares. The swollen mucous membrane, espe- 
cially at the posterior end of the lower turbinated bones, may be lobulated, 
papillate, or project as a polypus. Breathing through the nostrils is 
obstructed, and the patient becomes a mouth-breather, as in chronic fol- 
licular pharyngitis, a condition which often accompanies chronic rhinitis. 
The expression is dull and the voice is nasal. Taste and smell are lost, 
and hearing is often impaired from extension of the inflammation to the 
pharynx. There is abundant mucopurulent secretion, which, especially 
in children, is seen to ooze from the nostrils, causing eczema of the nose 
and lips. Crusts formed of the dried secretions and perhaps contain- 
ing blood are frequent both within the nose and upon the lip. Slight 
epistaxis often occurs, and is frequently excited by picking at the nose 
to relieve irritation from the crusts. The septum has occasionally been 
perforated in the course of time by the picking finger. 

In atrophic rhinitis the mucous membrane is thin and dense from 
atrophy of the glands and sclerosis of the interstitial tissue. It is covered 
with crusts of a green or gray color, producing a constant sense of irrita- 
tion, in consequence of which the patient frequently picks at the nose and 
removes the crusts, often with the production of bleeding. The nasal 
cavities are of large size. The especial characteristic is the extremely 
fetid discharge, ozcena, the odor from which often is not recognized by 
the patient. The ozsena may be associated also with a deep-seated 
ulceration, in which case syphilis, tuberculosis, or an impacted foreign 
body is likely to be the cause. Chronic rhinitis is greatly benefited by 
treatment, which should be early instituted to prevent a possible deafness, 
persistent neuralgia, or retarded mental development. 

Treatment. — The treatment of both hypertrophic and atrophic 
rhinitis is chiefly surgical, consisting in the application of various reme- 
dies and the removal of hypertrophied or abnormal parts. The results of 
the continuance of the local disease are so serious, and the treatment is 
so complicated and special, that in a treatise like the present it is im- 
possible to do more than refer to special works upon the matter, and to 
say that unless the practitioner shall have had sufficient training in the 
use of instruments and in the making of local applications to the nose, 
it is better to refer the case directly to the specialist. Palliation can 
be obtained by the use of douches containing various antiseptic or de- 



704 



DISEASES OF THE RESPIRATORY APPARATUS. 



odorizing solutions, which should usually be distinctly alkaline. (See 
formulas 13 and 14.) 

AUTUMNAL CATARRH. HAY FEVER. ROSE COLD. 

Definition. — A periodical affection of the naso-pharyngeal mucous 
membrane, often ending in asthma, and produced in certain persons by 
special irritants. 

Etiology. — The occurrence of a peculiar form of acute catarrh at the 
end of May or early in June and lasting three or four weeks has long 
been recognized both in this country and in England, though rarely seen 
upon the Continent. This affection has been designated June cold, rose 
cold, hay fever, or hay asthma, and its origin is attributed to the pollen 
of certain grasses and cereals. Morrill Wyman first made conspicuous the 
more serious autumnal catarrh closely allied to June cold in method of 
origin and symptoms. Essential in the production of both is a nervous 
temperament, exposure to the exciting causes, and excessive sensitive- 
ness of the nasal mucous membrane. The nervous temperament is often 
inherited, since successive generations in certain families are sufferers. 
The exciting causes are present in the atmosphere towards the end of 
May and about the 20th of August. According to Wyman, they are less 
frequent in the cities in June than in September. The sufferer in the 
United States may escape an attack when in Europe. The sensitiveness 
of the nasal mucous membrane is often sharply localized, either accom- 
panied with or independent of an obvious lesion, as shown by the relief 
which has rapidly followed the local treatment of the sensitive spot. The 
exciting causes are to be found not only in the pollen of certain grasses 
and cereals, especially in new- mown hay, but also in the emanations from 
various flowers, and even from fruits. The inhalation at other times of 
various irritants often produces an attack of coryza or asthma in sufferers 
from the periodical catarrh. 

Symptoms. — At or about the stated dates the patient notices an itch- 
ing in the mouth, nose, or throat, and a sense of fulness or weight in 
the frontal region. In the course of a day or two there is itching of the 
eyelids, which are puny, and the nasal mucous membrane becomes swollen, 
reddened, and so irritated that a violent attack of sneezing results, which 
is accompanied by a profuse watery discharge from the nostrils, often 
continuing throughout the day. Paroxysms of sneezing occur, at first 
in the morning, and later at irregular times, and are accompanied by 
more or less febrile disturbance and a sense of prostration. The appetite 
is poor, and the senses of taste, smell, and hearing are blunted. The 
throat becomes sore, and in the course of a fortnight the bronchial mucous 
membrane is irritable and a dry cough is frequent. At this time asth- 
matic paroxysms are likely to occur. The immediate symptoms of the 
disease cease at the end of a month, or earlier in case of frost, and the 
patient, weakened more or less in mind and body, rapidly recovers. 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 705 

According to Wyinan, autumnal catarrh differs from the June catarrh 
essentially in the greater severity of the symptoms. It is distinguished 
from simple catarrh by the itching of the eyes, nose, and throat, the pro- 
fuse discharge, protracted course, terminal asthma, persistent periodicity, 
and the production of the paroxysm by definite irritants. 

Prognosis. — The liability to the June or summer catarrh usually 
disappears after the age of forty. The autumnal catarrh, on the con- 
trary, ordinarily persists throughout life, even to extreme old age. The 
severity of the paroxysm diminishes in advancing years, and occasion- 
ally varies from time to time in the course of years. 

Treatment. — The treatment of hay fever based upon the theory that 
the disease is a neurosis, to be controlled by the use of arsenic and 
measures for the upbuilding of the nervous system, is of no avail, gen- 
eral treatment having no value other than that of sustaining the system 
against the exhaustion produced by the local disease. It is maintained 
by various specialists that local treatment will suffice to cure a large 
percentage of cases, — a statement which, however, still needs confirma- 
tion. The local curative treatment consists in the surgical removal of 
deformities, destruction by cauterization of sensitive portions of the 
mucous membrane, and the making of various local applications. It 
requires great skill in the use of instruments, and, therefore, especial 
training on the part of the practitioner. 

The local palliative treatment consists in the employment of certain 
drugs having the power of benumbing sensitive nerve-endings. Among 
these may be mentioned potassium bromide, a solution of which (ten 
grains to the fluidounce) may at first be carefully applied to sensitive 
spots, afterwards more freely used and also increased in strength. Anti- 
pyrin seems also to have some effect, and cocaine will almost invariably 
give temporary relief. The free use of cocaine in hay fever, and especially 
the employment of it by means of sprays to be used at the discretion of 
the patient, has in a large number of cases produced the narcotic habit, 
and is to be strongly gainsaid. If the cocaine must be used by the 
patient for relief, it should be in the form of bougies made with cacao 
butter, which will melt in the nostril : each bougie should contain one- 
eighth to one-quarter of a grain of cocaine. In this way much smaller 
amounts of the alkaloid suffice than with the spray, and the systemic 
excitement is largely avoided. For the relief of asthma the various 
narcotics employed in asthma may be given. In the excessive violence 
of the asthmatic paroxysms of hay fever hypodermic injections of mor- 
phine with atropine may be required, but their use is attended with dan- 
ger of the narcotic habit. 

The climatic treatment of hay fever is, we believe, almost invariably 
successful in preventing the attacks during the treatment ; in some cases 
when the attacks have been thus controlled during a series of years the 
tendency greatly lessens or entirely disappears. 

45 



706 



DISEASES OF THE RESPIRATORY APPARATUS. 



The way in which climatic treatment acts is at present inexplicable. 
Thus, the disease exists both in America and in Europe, and it is certain 
that in a large number of American cases the attack is prevented simply 
by travelling in Europe, while it is stated by European physicians that 
the European can avoid the attack by coming to America. A certain 
degree of elevation above the sea is often effective : thus, in Europe relief 
is often obtained by going to the high Alps, and in America by going to 
the higher regions of the Alleghanies, as the summits of the Catskills, or to 
Whitefield, Mount Washington, Bethlehem, Franconia, or other localities 
in the White Mountain district. The Eocky Mountains furnish probably 
innumerable localities of exemption. 

Mere " northing" also brings relief to many: thus, cases escape by 
going to Cape Breton. Life in the primeval forest — at least in the so- 
called " North Woods,' 7 the primeval forest of Northern America — is an 
almost sure preventive : hence the Adirondacks, Maine, the Canadas, 
afford relief to many. We have seen the invalid going out of the North 
Woods during the hay fever season gradually in twenty-four hours de- 
velop his hay fever as he passed from the dense forest through the clear- 
ings to the open country. Mackinac Island and Georgian Bay are re- 
sorted to with asserted success, but in our experience only greatly lessen 
the severity of the attack. 

Usually residence on the sea, in a vessel, or on a small barren island 
is prophylactic : hence Beach Haven and Fire Island are noted American 
resorts. In islands situated close to land hay fever subjects may be com- 
fortable when the wind is off the sea, but immediately develop distress- 
ing symptoms when the land breeze blows. 

DISEASES OF THE LARYNX. 

ACUTE LARYNGITIS. 

Etiology. — Primary and secondary forms of acute laryngitis are to 
be recognized. The former is the result of exposure to cold and wet, and 
of the action of irritants inhaled or swallowed. The occurrence of epi- 
demics of laryngitis suggests that at times the irritant may be infectious. 
Excessive strain of the voice, whether sudden or prolonged, is also a fre- 
quent cause. Secondary laryngitis results from the extension of inflam- 
mation from the naso- pharyngeal or the tracheal mucous membrane, 
especially when occurring in the sequence of acute infectious diseases, 
as scarlet fever, measles, diphtheria, influenza, whooping-cough, variola, 
erysipelas, and typhoid fever, or of chronic infection, as syphilis and 
tuberculosis. Secondary laryngitis also occurs as the result of injury to 
the larynx or neighboring parts, and of inflammation of the pharynx 
and the neck. 

Laryngitis accompanied by the formation of a false membrane consti- 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 707 

tutes the fibrinous laryngitis, membranous or pseudo-membranous croup, of 
authors. It is usually diphtherial, but the bacillus of diphtheria may be 
absent and other bacteria, especially streptococci, be present. A fibrin- 
ous laryngitis may occur in various infectious diseases, notably scarlet 
fever, which are wholly independent of true diphtheria ; or it may result 
from the inhalation of irritating gases, vapors, and steam, or the local 
action of caustics. 

Varieties. — Acute laryngitis is either superficial or deep-seated, and 
the inflammatory changes may be limited to definite portions of the 
larynx, as the epiglottis, the vocal cords, or the hypoglottic region, or 
all parts of the larynx may be simultaneously diseased. The superficial 
varieties of inflammation are the catarrhal and pseudo-membranous, the 
former being characterized by redness and swelling of the mucous mem- 
brane, and by the presence of a mucous or muco-purulent secretion, and 
occasionally of ecchymoses and erosions. The characteristics of pseudo- 
membranous laryngitis are mentioned in detail in the article on Diph- 
theria. Phlegmonous laryngitis is the deep-seated variety of acute 
laryngitis, and is characterized by a serous, fibrino-serous, or cellular 
infiltration of the submucous tissue, tending towards resolution, suppu- 
ration, or necrosis with gangrene. The region below the vocal cords is 
the part of the larynx in which the phlegmonous inflammation is espe- 
cially likely to occur. 

Symptoms. — Acute laryngitis is either mild or severe from the outset, 
although, especially in children, mild symptoms may assume rapidly a 
severe type. Acute catarrhal laryngitis, or acute laryngeal catarrh, is 
the variety of most frequent occurrence, and is characterized early by a 
tickling or burning sensation in the larynx, accompanied by a dry cough. 
The voice soon becomes husky or hoarse, and in the course of a few days 
may be reduced to a whisper, in consequence of swelling and impaired 
mobility of the vocal cords. The cough, although at first dry, is later 
followed by the raising of a viscid or opaque yellow sputum, small in 
quantity, and perhaps streaked with blood. In young children in whom 
the glottis is small the cough is high-pitched, the inspiration is noisy, 
and spasm of the glottis is frequent during the paroxysm of cough, in 
consequence of which the face becomes purple in the attempt to force air 
through the contracted glottis. Attacks of dyspnoea associated with 
hoarseness and a barking cough— false croup— are frequent, especially at 
night, awaking the child from sleep, and are induced both by spasm and 
by the accumulation of secretion in the glottis. These attacks not infre- 
quently occur for a few nights in succession, the child during the daytime 
being in apparent comfort. 

In acute catarrhal laryngitis of the adult there are but little elevation 
of temperature and but slight constitutional disturbance. In children, 
on the contrary, there aYe often fever, headache, and some prostration. 

In severe acute laryngitis, which is usually either membranous or 



708 



DISEASES OF THE RESPIRATORY APPARATUS. 



phlegmonous, the obstruction to the larynx is so considerable as usually 
to cause marked dyspnoea. In the phlegmonous variety the disturbance 
of breathing may progress with great rapidity, a condition of apparent 
comfort changing in the course of a few minutes to one of serious, if not 
of fatal, dyspnoea. The attack is announced by a chill, followed by a 
temperature of 102° or 103° with severe pain referred to the larynx 
and aggravated by coughing and swallowing. The larynx is tender to 
the touch. 

Diagnosis. — The local irritation, dry cough, and hoarse voice are 
sufficiently characteristic of acute laryngitis, and the use of the laryngo- 
scope will show redness of the affected part, and perhaps swelling of the 
mucous membrane, which in severe laryngitis may be limited to the hypo- 
glottic region. In non- diphtherial cases of pseudo- membranous laryn- 
gitis the symptoms at the outset are those of an acute catarrhal laryngitis, 
but there are a constant barking or crowing character to the cough and 
persistent hoarseness of voice. After two or three days the respiration 
becomes more difficult, and paroxysms of coughing occur, associated with 
symptoms of suffocation, whence the term croup. The presence of 
pseudo-membrane in the pharynx, or the expulsion of membrane from 
the larynx, warrants the diagnosis of this form of laryngitis ; but per- 
sistent suppression of voice between the paroxysms and continuing evi- 
dences of laryngeal obstruction are of most serious import. False croup 
suddenly occurs, especially at night, in children comparatively free from 
serious disturbance of the larynx during the day and at bedtime. The 
rapid relief following treatment is opposed to the course of laryngeal 
obstruction in diphtheria or croup. 

Prognosis. — Acute catarrhal laryngitis is a disease lasting from a few 
days to a fortnight. The prognosis in adults is favorable. In young 
children the laryngeal catarrh is likely to extend into the trachea and 
bronchi, and then may end in a severe if not dangerous bronchitis. The 
possibility that relatively mild forms of acute laryngitis both in the adult 
and in the child may suddenly become dangerous by the production of 
oedema of the glottis is always to be remembered. The prognosis in false 
croup is usually very favorable ; in pseudo- membranous it is very serious. 

Treatment.— Unless the attack of acute laryngitis be very severe, 
the patient should be confined simply to his room, not necessarily to bed. 
Talking and all use of the voice should be strictly forbidden. The diet 
should be light but nutritious. In the beginning of the attack the potas- 
sium citrate mixture (see formula 16) may be freely used. With it, if 
there be fever, aconite should be given. Judicious purgation by salines 
may be advantageous. 

The local applications are internal and external. At first the pa- 
tient should simply inhale steam (vapor) or atomized water (preferably 
slightly alkalinized), or lime water, at short intervals. Later, when 
secretion has been in a measure established, ammonium chloride solution 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 709 

(five to twenty grains to the ounce) may be freely used with the atomizer, 
or compound tincture of benzoin (twenty to thirty drops), vaporized in 
hot water or in an inhaler, may be employed. Very late in the disease, 
when secretion is free, the vapors of terebene or of oleum pini sylvestris 
are sometimes serviceable. Externally, ice-bags may be applied around 
the throat, but usually the hot- water pack is preferable. Several thick- 
nesses of flannel wrung out of hot water should be wound around the 
neck, and the whole covered with oil-silk and a towel. A few drops 
of turpentine upon the flannel will render this application actively 
counter- irritant. 

In the false croup of childhood, an emetic of ipecacuanha, aided by 
the hot bath, will ordinarily suffice to put an end to the immediate par- 
oxysm. If it does not, potassium bromide with chloral may be exhibited, 
or a whiff of ether or of chloroform may be given. Hot moist applica- 
tions, or mustard plasters, around the throat are sometimes of service. 
Between the paroxysms the child should usually be kept in the house, 
and should be treated for catarrhal laryngitis, with the addition of cer- 
tain drugs to overcome the tendency to spasm. Potassium bromide, 
being entirely safe, should be freely administered. Chloral, cautiously 
employed at bedtime, is often of service. A dose of castor oil should 
usually be given directly after the first attack. In pseudo- membranous 
croup the treatment should be that of diphtheria without antitoxin. 
Emetics should be freely used, to remove, if possible, the membrane. 

CHRONIC LARYNGITIS. 

Etiology. — Frequent or prolonged exposure to the causes of acute 
laryngitis is important in the etiology of the chronic variety. Of especial 
significance are the trades demanding exposure to a dust-laden atmosphere 
or the professions requiring continuous or excessive use of the voice. 
Chronic passive congestion of the mucous membrane from obstruction to 
the circulation through the heart or lungs may cause chronic laryngitis, 
and the excessive use of alcohol or tobacco is important in etiology. 
Tuberculosis and syphilis as causes of laryngitis are considered in the 
articles on these diseases. Chronic laryngitis is a disease of adults, and 
occurs oftener in men than in women. 

Symptoms.— There is a sensation of tickling or pricking in the larynx, 
likely to be followed by a paroxysm of coughing, and aggravated by the 
use of the voice, a dusty atmosphere, or a sudden change of temperature. 
There is a frequent tendency to clear the throat, and the coughing results 
in the raising of a small quantity of dense opaque gray mucus. In con- 
sequence of swelling of the vocal cords or weakness of their muscles, the 
voice is husky, variable, and may eventually be in whispers. Difficulty 
of swallowing is sometimes present. In chronic hypoglottic laryngitis 
the mucous membrane and submucous tissue may be so thickened as to 
cause persistent dyspnoea. On laryngoscopic examination the mucous 



710 



DISEASES OE THE RESPIRATORY APPARATUS. 



membrane is usually swollen, of a dark-red color, and the surface may 
be granular or eroded. At times circumscribed or diffuse thickening 
of the posterior portion of the cords, pachydermia laryngis, is to be 
seen. As a rare condition the mucous membrane is found atrophied. 
Chronic laryngitis is an affection usually greatly relieved by treatment, 
but relapses are frequent, from the difficulty of avoiding exposure to the 
causes. 

Treatment. — In chronic laryngitis it is essential to treat carefully 
any adenoid growths or deformities or enlargements about the nasal pas- 
sages, and to see that the subject avoids the use of tobacco, alcohol, and 
very rich foods, as well as abstains from loud or excessive talking and 
from living in overheated rooms. Usually in chronic laryngitis, as in 
recurring acute laryngitis, exposure of the neck and frequent ablutions in 
cold water are beneficial. The general health should be attended to, and 
local applications made to the mucous membrane of the larynx. These 
applications cover almost the whole range of local alteratives and astrin- 
gents, — silver nitrate, iodine and glycerin, potassium chlorate and potas- 
sium bromide, zinc salts, bismuth preparations, tannic acid, etc. Any 
ulcerations should be carefully touched with silver nitrate or other appro- 
priate substance. In tubercular cases iodoform is especially valuable. 
It may be insufflated two or three times a day in conjunction with a 
little morphine or cocaine, after the larynx has been cleansed with a 
slightly antiseptic spray. 

When ulceration about the epiglottis interferes with swallowing, the 
application of cocaine before the meal may afford relief for a time, but 
usually it soon loses its power. According to Wolfenden, when the epi- 
glottis is so destroyed that swallowing becomes almost impossible, milk 
may be sucked up through rubber tubing when the patient hangs his 
head downward over the side of the bed. 

In syphilitic laryngitis antisyphilitic remedies must be carefully used 
in addition to local applications. In many cases tracheotomy should be 
resorted to. It not only affords relief, but sometimes seems to benefit 
the larynx permanently by putting it out of use. 

(EDEMA OF THE LARYNX. 

Etiology. — Swelling of the mucous membrane of the larynx from 
the presence of a serous fluid representing the exudation of inflammation 
or the effusion of dropsy takes place particularly in the epiglottis, in the 
aryepiglottic folds, and sometimes in the false cords. The inflammation 
may originate in the larynx, especially from its injury from within or 
from without, or may extend from neighboring parts, as the pharynx, 
the neck, or the submaxillary region. It is often an accompaniment of 
tuberculosis, syphilis, and cancer of the larynx or the pharynx. The 
dropsical effusion may be due to local causes, as pressure on the jugular 
veins by tumors of the thyroid, enlargement of the lymph -glands of the 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 711 

neck or mediastinum, and aneurism of the arch of the aorta. CEdema 
of the larynx may be due also to the general causes of dropsy, as disease 
of the kidneys, heart, and lungs. It is said to have followed the use of 
potassium iodide. 

Symptoms. — Dyspnoea from obstruction of inspiration and expiration 
and a sense of constriction referred to the larynx are the characteristic 
symptoms. The dyspnoea often rapidly progresses, and may prove fatal 
within a few hours, or even in a few minutes, unless relief is obtained. 
The oedematous epiglottis may be seen if the back of the protruded 
tongue is depressed, or may be felt with the tip of the finger. 

Treatment. — When in laryngitis there is a tendency to oedema of 
the larynx, the case must be carefully watched. Ice may be used exter- 
nally, and also by the mouth. The internal medicaments and the local 
applications to the larynx should be much the same as in acute catarrhal 
laryngitis. Stimulating substances may, however, be used somewhat 
sooner than in the ordinary cases. As soon as there is pronounced 
oedema, cocaine should be used as a local anaesthetic, and the epiglottis 
be well scarified. The practitioner should always be ready to perform 
tracheotomy at a moment's notice. Nearly all the deaths that have oc- 
curred from the disorder could have been prevented by an early operation. 

TUMORS OF THE LARYNX. 

Of the tumors which occur in the larynx, the myxoma, fibroma, li- 
poma, chondroma, angioma, adenoma, and cyst are benignant, while the 
sarcoma and cancer are malignant. Fibroma is oftenest found, especially 
as the papillary fibroma or papilloma of the true cords, and may be 
present at birth. It not infrequently occurs in the course of chronic 
laryngitis and in the vicinity of ulcers of the larynx. Tumors arise 
from any portion of the larynx, but especially from the vocal cords or 
their immediate vicinity. They are usually rounded, often peduncu- 
late, the surface frequently warty, and sometimes attain a considerable 
size. 

They may be so situated and so small as to produce no symptoms. As 
a rule, the first manifestation is hoarseness, which persists for a long time 
and may end in aphonia. Cough is frequent when the tumor is situated 
in the vicinity of the glottis, and dyspnoea arises if the size of the tumor 
is such as to obstruct the larynx or its shape and mobility permit sudden 
closure of the glottis, under which circumstances spasms of dyspnoea 
threatening suffocation result. Pain and difficulty in swallowing are rare. 
The prognosis is favorable except in the case of malignant tumors, as 
the growth early produces laryngeal symptoms and removal with the aid 
of the laryngoscope is easy. 

Treatment. — The treatment of tumors of the larynx is surgical re- 
moval. 



712 



DISEASES OF THE RESPIRATORY APPARATUS. 



DISEASES OF THE TRACHEA AND BRONCHI. 

Inflammation of the trachea, trachitis, rarely occurs independently of 
disease of the larynx or bronchi ; hence the primary symptoms are those 
of a laryngitis or of a bronchitis. Affection of the trachea is indicated 
by the occurrence of pain or tenderness in the course of this tube. 

When the inflammation of the mucous membrane of the respiratory 
tract is limited particularly to the bronchi, the condition is known as 
bronchitis. According to the localization of the inflammation the dis- 
tinction is drawn between bronchitis of the larger and medium- si zed 
tubes, simple bronchitis, and bronchitis of the smallest tubes, capillary 
bronchitis. Simple bronchitis is either acute or chronic ; capillary bron- 
chitis when not tubercular is always acute. A further distinction is based 
upon the nature of the product of the inflammation. Usually it represents 
an increased quantity and modified quality of the secretion which nor- 
mally appears on the surface of the membrane, and hence is then desig- 
nated catarrhal bronchitis. Earely a cast of a bronchus and its branches 
formed of fibrin or other material represents the inflammatory product, 
and the condition is then known as membranous or fibrinous bronchitis. 

ACUTE BRONCHITIS. ACUTE BRONCHIAL CATARRH. 

Etiology. — The growing tendency at present is to regard micro- 
organisms as the immediate cause of acute bronchitis. This is generally 
admitted in epidemic bronchitis and in the bronchitis of influenza, 
whooping-cough, diphtheria, tuberculosis, measles, and erysipelas. It is 
considered probable in the bronchial inflammation of variola, typhoid 
fever, malarial fevers, and syphilis. Since various pathogenic bacteria 
have been found repeatedly in bronchi free from disease, predisposing or 
favoring causes are obviously necessary. Most common of these is ex- 
posure to frequent and sudden changes of temperature and moisture, 
which oftenest occurs in the spring and fall, at which seasons cases of 
acute bronchitis are most numerous. The inhalation of dust, or of irri- 
tating gases, vapor, or steam, is also to be included among the causes. 
Conditions interfering with the freedom of respiration, whether deformed 
thorax, disease of the lungs, heart, or kidneys, gout, rickets, or scrofula, 
and the weakness due to alcoholism or occurring in infancy and in old 
age, are also favoring causes. 

Morbid Anatomy. — The inflamed mucous membrane is reddened and 
swollen, from congestion of the blood-vessels and from the presence of a 
serous and cellular exudation in the mucous membrane. The surface is 
covered with secretion, which varies in characteristics according to the 
stage of inflammation. When the smaller bronchi are inflamed the 
secretion exudes on pressure, and patches of atelectasis and nodules of 
broncho-pneumonia are frequently associated. 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 713 

Symptoms. — In simple bronchitis the attack often begins with sneez- 
ing and hoarseness, indicative of irritation of the nasal and laryngeal 
mucous membrane, or at the outset the symptoms are referred to the 
bronchi, and consist of a sense of constriction or a tickling or a raw 
feeling beneath the sternum or in the region of the trachea. If the 
inflammation is localized in the trachea or in the bronchus or the bronchi 
of the right or the left lung, the seat of the discomfort corresponds. With 
these incipient symptoms there may be slight fever, perhaps preceded 
by chilly sensations, backache, muscular pains, and weakness. Cough is 
of early occurrence, is at first occasional, dry, and annoying, and in 
nervous persons is often paroxysmal and unduly violent. It is sometimes 
so excessive as to cause vomiting. In the course of a day or two a glairy 
secretion is raised, at first in small quantity. As the cough loosens the 
secretion increases in quantity, becomes opaque and eventually yellow, 
and not infrequently contains specks or streaks of blood. The sputum 
consists of a hyaline or fibrillated material in which are mucous and 
pus corpuscles and pavement, cylindrical, and ciliated epithelium. Eed 
blood-corpuscles are often seen with the microscope when there is no sug- 
gestion of blood from the appearance of the sputum. On physical ex- 
amination of the chest the sounds on percussion are essentially normal. 
On auscultation there is no decided alteration of the respiratory murmur. 
Rales are present, at first dry, sonorous, or sibilant, and changing in qual- 
ity, even disappearing after coughing. As the formation of secretion 
increases, moist rales are to be heard, both coarse and fine, during inspira- 
tion and expiration, and are accompanied by dry rales. The coarse rales 
are to be recognized on palpation, and are not infrequently heard at some 
distance from the patient. 

In mild bronchitis relief to the discomfort usually occurs as the 
secretion becomes profuse and easily expelled. The disease lasts a week 
or ten days, and the discomforts are generally insufficient to compel the 
patient to stay in bed. 

Capillary bronchitis is present when the inflammation extends to the 
small bronchi, and as a rule is diffused over a wide area in both lungs. 
The smaller bronchi may be inflamed at the outset, or the attack may 
begin as a simple bronchitis, becoming progressively worse as the inflam- 
mation extends into the bronchioles. The severe symptoms indicative of 
capillary bronchitis may exist, therefore, from the beginning or develop in 
the course of simple bronchitis. Dyspnoea, often extreme, especially in 
infants, is the conspicuous feature, manifested by rapid and superficial 
breathing, movements of the nostrils, and exaggerated use of the accessory 
muscles of respiration. The cervical muscles become prominent. The 
lower ribs are retracted on inspiration. The skin is of a bluish tint, and 
the jugular veins are distended. The cough is frequent and short, and the 
secretion is moderate in quantity, and is usually swallowed by young 
children. The temperature is 103° F., or more, and the pulse quick and 



714 



DISEASES OF THE RESPIRATORY APPARATUS. 



feeble. The patient takes but little nourishment, loses strength rapidly, 
is restless, may be drowsy or delirious, and, if a child, may have convul- 
sions. Percussion is likely to be negative, the dulness from areas of 
broncho-pneumonia and atelectasis being concealed by the deep seat or by 
the hyperresonance of neighboring portions of the lung. The respira- 
tory murmur varies in quality in different parts of the chest, is either 
feeble or harsh, and the expiration is prolonged. It is often obscured 
by numerous fine moist rales, diffused or circumscribed, heard both on 
inspiration and on expiration, especially in the lower half of the lungs. 
Coarse moist rales and dry rales are also to be heard, but are less char- 
acteristic than the fine moist rales of the localization of the disease in the 
smaller bronchi. Capillary bronchitis usually lasts two or three weeks, 
and is often a cause of death in old persons and in infants. The severe 
forms of capillary bronchitis end in broncho-pneumonia, and will be 
further considered in the article on broncho-pneumonia. 

Diagnosis. — Simple bronchitis is readily recognized by the cough, 
the variety of rales, and the slight constitutional disturbance. The dis- 
tinction between simple bronchitis and a mild attack of influenza during 
the occurrence of an epidemic of the latter is often arbitrary, and is based 
upon the absence of the characteristic symptoms of influenza as the 
disease progresses. The distinction between simple bronchitis and capil- 
lary bronchitis is one of degree. Mild symptoms indicate localization 
of the inflammation in the larger bronchi ; dyspnoea, high fever, and 
abundant fine moist rales indicate its seat in the smaller bronchi. In in- 
fants in whom cough may be slight and expectoration absent, dyspnoea 
and fever may be the only prominent symptoms. The distinction be- 
tween capillary bronchitis and lobular pneumonia or broncho-pneu- 
monia is one of inference, based upon the severity and duration of the 
disease. 

Treatment. — The treatment of acute bronchitis should vary with the 
intensity of the attack. In mild cases it may be necessary only to keep 
the patient in-doors, but when the symptoms are severe confinement 
to bed should be enforced, whilst the air should be rendered moist by 
means of the steam atomizer or other device. A light, nutritious, sup- 
porting diet should be given. Free external counter-irritation is very 
important ; it should be applied alternately over the back and the chest. 
The turpentine stupe or the mustard plaster may be used, but ordi- 
narily it is better to make a poultice containing one part of mustard 
to from five to seven parts of flaxseed- meal, which may be left on for 
many hours. In children the so-called jacket-poultice is very valuable j 
it consists of thin flannel made into a bag of such shape that it can be 
applied closely around the chest and kept in place by tapes tied over the 
shoulder and in front ; to prevent sagging of the contents to the bottom 
of the bag, a line of stitching should be run lengthwise through the 
centre. The jacket-poultice should be put on as hot as can be borne j 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 715 

when there is fever it will not get cold for many hours, and need not 
be changed for from eight to twelve honrs. In many cases five to ten 
per cent, of mnstard may be pnt in the flaxseed-meal with advantage. 
When the skin becomes sore, or when it is not convenient to use the 
jacket-poultice, many practitioners wrap the child's chest in cotton or 
woollen batting, and cover this with an oil-silk jacket, so that by reten- 
tion of the perspiration a moist application can be obtained. 

The keeping in of the heat of the body by these appliances is a very 
serious objection to their use when there is high fever ; the cotton batting 
is probably more objectionable than is the poultice ; indeed, when the 
bodily temperature is high, cold applications (ice poultices or compresses 
wet with cold water) to the chest are preferable to either the poultice or 
the batting. When bronchitis persists and becomes subacute, the official 
pitch plaster, or the official pitch plaster with cantharides (warming 
plaster), placed between the shoulders, often acts very well. When the 
disease locates itself and remains obstinate in one lobe of the lung, even 
though the presence of catarrhal pneumonia cannot be demonstrated, a 
large blister will often be found of the greatest service. When there is 
great bronchial irritation, relief may be afforded by the inhalation of 
watery vapors ; but drug inhalations have little value in acute bronchitis. 

In the first stage of acute bronchitis the chief indication is to favor 
secretion and thereby aid in resolution. In the robust patient a forming 
bronchitis may sometimes be aborted by the administration of sufficient 
doses of veratrum viride (one drop of the fluid extract) or tartar emetic 
(one-twelfth to one-eighth of a grain) every half-hour until free vomiting- 
is induced. Such treatment is too violent, however, for ordinary pur- 
poses, but we have used it with success in robust public speakers or other 
persons who felt compelled to fulfil some business engagement in a short 
time. After the vomiting has been induced and the relief of the bron- 
chitis obtained, alcoholic stimulants may be used. In the case of chil- 
dren or feeble adults neither veratrum viride nor tartar emetic should 
be administered for bronchitis. 

The most effective general remedy is the potassium citrate mixture 
(see formula 16), with ipecacuanha, apomorphine, or tartar emetic, in 
accordance with the nature of the individual case. One ounce of potas- 
sium citrate may be exhibited within the twenty-four hours ; sometimes 
a single half-ounce of the salt given at one dose in the evening will put 
an end to a forming cold. Flaxseed tea and other demulcent drinks are 
often grateful to the patient. 

When fever exists, aconite may be added to the potassium citrate 
mixture. Antipyrin, phenacetin, and other drugs of the class are often 
useful, and may be employed witli greater freedom than in infectious 
diseases. When, however, there is any feebleness, care must be exercised 
in their use. If the temperature remains above 103° F., there should 
be no hesitancy in the external use of cold sponging or of cold bat lis 



716 



DISEASES OF THE RESPIRATORY APPARATUS. 



if necessary ; with children the tepid bath (90° F. ) is usually preferable 
to cold sponging. 

In the second stage of bronchitis, when there is secretion with relaxa- 
tion, the stimulant expectorants are useful. Ammonium chloride may 
be considered to lie half-way between the sedative and the stimulant 
expectorants, and therefore to be especially useful in the opening period 
of the second stage. It should be given at intervals of not less than two 
hours, in doses of from ten to fifteen grains ; it is often preferred simply 
dissolved in water, or may be exhibited in accordance with formula 17. 
With it may be at first combined ipecacuanha or apomorphine. Senega 
and squill are of very doubtful value : we have never been able to 
perceive any distinct influence from them. 

At a later period, after the establishment of free secretion, certain 
volatile oils are very effective. Of these oil of eucalyptus may usually 
be first employed, as the least stimulating • oil of garlic, in the form 
of syrup of garlic, is often very useful in the protracted bronchitis of 
children. Terebene is one of the most valuable of the class. Oil of 
sandal wood, of copaiba, or of cubeb may be tried if other remedies 
fail or have been used until the lungs have become accustomed to them. 
Compound tincture of benzoin (five to ten drops on sugar) every two 
hours is sometimes useful. Terebene and the various oils are best given 
in capsules (three to five minims each). Oreasote, or guaiacol or its car- 
bonate, is often very effective when the bronchitis becomes subacute and 
persists with free expectoration. (The treatment of capillary bronchitis 
is given in the article on Broncho -Pneumonia, page 763.) 

The proper treatment of the symptom " cough" involves the under- 
standing of the value and object of cough. This act is necessary for the 
relief of the lungs from various exudations. Cough may be produced by a 
nervous or an inflammatory irritation of the mucous membrane at a time 
when there is nothing to be coughed up, or if there be exudation to be 
expelled the amount of cough present may be in excess of what is need- 
ful. In either of these cases the cough becomes an evil, to be done away 
with or checked as far as practicable. On the other hand, when there 
is excessive exudation, and especially if there be at the same time great 
weakness of the patient, as in infancy or in old age, the cough may not 
be sufficient to bring about relief, in which case it must, if possible, be 
increased or replaced in some way. It is plain that the amount of cough 
which the patient has, taken by itself, is not a sufficient guide as to 
whether the cough is excessive or not. It is the relation between the 
cough and the work to be accomplished which must be considered by the 
practitioner. Cough can sometimes be allayed by the use of inhalations 
of vapor or fames of medicated sprays which lessen the irritation of the 
mucous membrane. Belladonna may be used in this way. (See Asthma.) 
When the cough is of laryngeal origin, cocaine is a valuable local remedy. 
In most cases excessive cough is to be checked by drugs which benumb 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 717 

the central nervous system : of these the most powerful is opium, which 
is, however, equally powerful in checking the secretion of the respiratory 
mucous membrane as well as in deranging digestion. When, therefore, 
as in the early stages of a bronchitis, it is desired to increase bronchial 
secretion, opium should not be employed. Again, excessively violent 
cough is especially seen in hysterical neurotic subjects, most of whom do 
not bear opium well, and with whom when the narcotic is borne there is 
danger of the formation of the opium habit. Hyoscyamus is tree from all 
objection and is much used ; it is, however, comparatively feeble and un- 
certain in its action, and must be given in full doses to accomplish any- 
thing. The bromides and antipyrin are, we think, more decided in their 
influence than is hyoscyamus. Codeine is much used by certain prac- 
titioners. In some cases chloroform given by the stomach in the cough 
mixture acts most happily. Prussic acid has been much used. The action 
of such agents as chloroform and prussic acid lasts only for a very short 
time, and to exert anything like a continuous influence the drug must be 
given at intervals of not more than an hour. 

In neurotic or hysterical subjects a bronchial irritation may be main- 
tained for weeks or months simply from a cough which is produced by a 
hyperesthesia of the mucous membrane. In such cases we have seen re- 
coveries rapidly follow the withdrawal of all expectorant remedies, and 
the free use of the antispasmodics just mentioned, alone or in combi- 
nation. Travel, with its change of air and scene, is especially useful in 
these cases. 

Whenever in acute bronchitis it is perceptible that the strength is 
waning, strychnine and cocaine should be administered. In the old, the 
alcoholic, and the feeble this condition is especially liable to arise. The 
strychnine may be added to the cough mixture, but in bad cases should 
be given hypodermically. An excellent plan is to give it and cocaine al- 
ternately every two hours, increasing the dose from one-thirtieth (strych- 
nine) and one-fourth (cocaine) rapidly until as much as one-sixteenth and 
one-half grain respectively are given, if it be found necessary. 

CHRONIC BRONCHITIS. CHRONIC BRONCHIAL CATARRH. 

Etiology.— Chronic bronchitis is essentially a disease of elderly 
people, and represents the results of repeated exposure to the causes of 
acute bronchitis. It is likely to occur in persons suffering from chronic 
disease of the heart, lungs, or kidneys, in scrofula, in gout, in eczema, and 
in alcoholism. In winter exacerbations are frequent ; in summer remis- 
sions occur. 

Morbid Anatomy. — The mucous membrane of the affected bronchi 
either is thickened, reddened, and the surface velvety, perhaps eroded, or 
is thin, smooth, and shining. Not infrequently there is a simultaneous 
occurrence of hypertrophy of the mucous membrane of the larger bronchi 
and atrophy of that of the smaller tubes. When there is abundance of 



718 



DISEASES OF THE RESPIRATORY APPARATUS. 



the secretion it readily escapes from the cut tubes. The muscular and 
elastic fibres in the wall are frequently hypertrophied and distinctly 
project into the canal. Dilatation of the bronchial tubes, peribron- 
chitis, and emphysema are frequently associated. 

Symptoms. — Persistent cough is the. conspicuous symptom of chronic 
bronchitis, and usually becomes aggravated with the approach of winter. 
It is mild or violent, constant or in paroxysms. The latter often occur 
at the beginning and end of the day, and may take place at night, dis- 
turbing the sleep of the patient. Violent paroxysms of coughing may 
be associated with dyspnoea, and the face become of a bluish tint, the 
superficial veins be distended, and the accessory muscles of respiration 
be brought violently in play. The physical examination of the chest, ex- 
cept for the recognition of rales, is practically negative unless emphy- 
sema or bronchitis is present. Sonorous and sibilant rales are to be 
heard the more abundantly the less the secretion, while moist rales, 
coarse and fine, are often present, especially in the lower and posterior 
portions of the lung. In general the course of chronic bronchitis ex- 
tends over a period of many years, and the health is not materially im- 
paired until emphysema, bronchiectasis, fibrous pneumonia, and dilated 
heart occur as complications, when dyspnoea, cyanosis, and dropsy are 
likely to result. 

The varieties of chronic bronchitis usually recognized are designated 
according to the quantity or quality of the discharge from the bronchi. 
In dry catarrh the smaller bronchi are affected, the secretion is scanty, 
tough, opaque gray. Dyspnoea is constant, and paroxysms of coughing 
are violent. The physical signs are those of emphysema combined with 
dry rales. When the chronic bronchial catarrh is associated with abun- 
dant purulent secretion the condition is known as bronchorrhoea, and a 
pint or more may be expectorated in the course of a day. The sputum 
varies in appearance according as mucus or pus predominates, and clumps 
of green or yellow pus may be present in a more gelatinous and trans- 
parent material. The more profuse the secretion the more likely is bron- 
chiectasis to be associated. In bronchorrhoea there is usually progressive 
loss of flesh and strength, and dropsy not infrequently occurs towards 
the end of life. The term serous bronchorrhoea is applied when the ex- 
pectoration is profuse, viscid, and clear, resembling mucilage. There is 
usually but little constitutional disturbance, and the patient may attain 
extreme old age. Putrid bronchitis results from the occurrence of putre- 
faction in the bronchial secretion, and is to be discriminated from the 
putrefactive condition occurring in gangrene of the lung by the absence 
of elastic fibres, and from that occurring in phthisical cavities by the 
absence of the bacilli of tuberculosis. A febrile temperature occasion- 
ally is present, the breath is fetid, and gangrene of the bronchial wall 
or foci of gangrenous broncho -pneumonia sometimes result. Several 
instances have been reported of abscess of the brain as a complication. 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 719 

In general there is progressive loss of flesh and strength, although the 
course of the disease is rapid when complicated with pulmonary gan- 
grene. 

Treatment. — In the management of a case of chronic bronchitis, 
if possible, the patient should be sent to a warm, dry, equable climate, 
where out-door life can be enjoyed at all times. This is especially true 
of those cases in which each winter brings a recurrent prolonged bron- 
chitis, the so-called u winter cough." If it is impossible to change the 
habitation of the person suffering from chronic bronchitis, every pre- 
caution should be taken to avoid exposure ; heavy under-flannels should 
be worn. Frequently the tendency to take cold can be modified by the 
daily use of the cold bath, commenced during the summer months and 
continued, and by the continuous administration for months of minute 
doses of arsenic (one-hundredth of a grain ter die), which remedy is also 
of value in the treatment of formed chronic bronchitis. 

Tonics, nutritious food, wine, cod-liver oil, regulated exercise, and all 
drugs and procedures which tend to strengthen the bodily health and 
vitality, are of the greatest service in chronic bronchitis. 

In attempting to modify the disease directly by drugs, the practi- 
tioner must select his expectorant according to the condition of the 
mucous membrane. In an acute exacerbation, with great dryness of the 
mucous membrane, the potassium citrate mixture may be employed. 
When, however, it is desired to increase secretion for a longer period, 
potassium iodide is preferable. The iodide may also be used in very 
small doses (five to ten grains a day) for weeks at a time, in order to 
aid in the absorption of exudations which have taken place into the 
mucous membrane. When there is excessive secretion, gallic acid (five 
to ten grains four times a day) may be very serviceable. In old cases, 
with nervousness, and especially when there is a tendency to abdom- 
inal flatulence from atony of the bowels, asafetida often gives temporary 
relief. 

The most generally useful expectorants are, however, the volatile oils. 
Of these, terebene, oil of eucalyptus, oil of sandal wood, oil of copaiba, 
oil of cubeb, and even oil of turpentine, may be from time to time em- 
ployed. Benzoic acid, pure or in the form of compound tincture of 
benzoin (five to ten drops every three hours on sugar), is an occavSional 
remedy. Creosote is among the most valuable of the drugs ; it should be 
given in capsule or emulsion, in slowly increasing doses, until thirty 
minims a day are taken or the limit of gastric tolerance is reached. Sul- 
phuretted hydrogen has been especially used by respiration, and many 
springs are now furnished with respiratory chambers. It may, however, 
be given in solution. It is often efficacious when there is much expecto- 
ration in a chronic bronchitis. From two to four ounces of the saturated 
watery solution may be administered by the mouth four or five times a 
day or until the breath has a perceptible odor. In the use of expecto- 



720 



DISEASES OF THE RESPIRATORY APPARATUS. 



rants it is essential to avoid disturbing the digestion, and also to vary the 
drug from time to time according as the mucous membrane of the lung 
appears to become accustomed to one remedy. 

When in chronic bronchitis there is failure of the respiratory func- 
tion, either from retention of secretion or from loss of the functional 
power of the lung by anatomical alteration, strychnine and cocaine are 
the chief reliances ; only under rare circumstances is the attempt to clear 
the lungs by the use of emetics justifiable. 

Counter- irritation in chronic bronchitis should be limited to parox- 
ysms of exacerbation or to the occasional use of pitch or other irritant 
plasters. Inhalations are frequently of value 5 terebene, compound tinc- 
ture of benzoin or other benzoic acid preparations, and various stimu- 
lating volatile substances of balsamic or terebinthinate nature may be 
used from time to time with advantage. 

In the advanced stages of chronic bronchitis there is almost always 
dilatation of the right heart, so that the treatment of cases eventually 
resolves itself largely into the treatment of chronic cardiac failure. 

MEMBRANOUS BRONCHITIS. 

Definition. — A localized inflammation of the bronchi, usually chronic, 
and characterized by the expulsion of an arborescent cast of a bronchus 
and its branches. 

Fibrinous casts are formed in the bronchi frequently in diphtheria, 
in fibrinous laryngitis of non-diphtherial origin, and in pneumonia. 
Hemorrhagic casts are at times formed from the aspirated blood in nose- 
bleed and cut-throat, and in the occurrence of pulmonary hemorrhage. 
In membranous bronchitis, however, inflammation of the bronchial mucous 
membrane is the primary condition, and has been designated plastic, 
exudative, fibrinous, and polypoid bronchitis or bronchiolitis. 

Nothing definite is known with reference to the causation of this 
affection. It occurs usually in adults, often in the vigorous and healthy, 
but frequently in pulmonary tuberculosis. It has been observed also in 
connection with cardiac disease, and a number of cases have been re- 
ported in which herpes zoster, pemphigus, and impetigo were associated. 
Cases of acute membranous bronchitis have been reported from time 
to time characterized by the sudden occurrence of fever accompanied 
with cough and a sense of substernal constriction. The physical signs 
are those indicative of a localized acute bronchitis, and the more exact 
nature of the disease is made evident by the expulsion of a bronchial 
cast, following which relief, perhaps merely temporary, is experienced. 
In the instances reported the occasional combination of a membranous 
tonsillitis and the frequent death from suffocation or pneumonia suggest 
that cases of diphtheria and pneumonia may have been regarded as acute 
membranous bronchitis. 

Chronic membranous bronchitis is the variety commonly encountered, 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 721 

and recurrent attacks are likely to take place at intervals of weeks or 
months over a period of years. Cough is the conspicuous feature, is 
sometimes paroxysmal, and generally is not sufficiently severe to interfere 
with the habits and occupation of the individual. Attacks of dyspnoea 
may immediately precede the expulsion of the cast, although often 
there may be no difficulty of breathing at any time. During the oc- 
currence of dyspnoea there is frequently more or less cyanosis. The 
physical signs are those of bronchitis, and, although respiration in the 
affected portion of the lung is likely to be feeble or absent, the physical 
examination of the chest is usually negative, with the exception of the 
signs of a bronchitis. The expulsion of the bronchial cast is the essen- 
tial feature, and is at times associated with more or less hemorrhage. 
The cast ordinarily appears as a rounded, flesh-like mass, in part, per- 
haps, composed of mucus and blood, and when unfolded in water assumes 
an arborescent character. The size of the cast varies in accordance with 
that of the bronchus affected. The cast is either hollow or solid, homo- 
geneous or laminated, and is composed of fibrin, more rarely of inspis- 
sated mucus, leukocytes, red blood- corpuscles, and Charcot crystals. The 
spiral fibres of Curschmann have been found in the cast. 

Although the prognosis of chronic fibrinous bronchitis is usually 
favorable, it is to be remembered that in nearly one-half of the cases 
reported as fibrinous bronchitis tuberculosis has existed, and the prog- 
nosis should be guarded until evidence of the latter disease has been re- 
peatedly sought for in vain. 

Treatment. — The treatment is that of chronic bronchitis. 

BRONCHIECTASIS. 

Definition.— Dilatation of the bronchi. 

Etiology. — Bronchiectasis is the result of conditions which produce 
a weakening of the wall of the bronchus, and an increase of the atmos- 
pheric pressure against it, especially from persistent coughing. Most 
important in the causation of weakness of the wall is chronic inflamma- 
tion of the bronchi, whether occurring in chronic catarrhal bronchitis, in 
tubercular bronchitis, or in consequence of the presence of foreign bodies. 
Bronchiectasis also occurs as the result of the obstruction of a tube by 
the pressure of tumors, the obliteration of alveoli in fibrous pneumonia, 
or interference with their expansion by chronic pleurisy. The atmos- 
pheric pressure is then exercised upon the unobstructed spaces in the 
lung, and a collateral, compensatory or vicarious bronchiectasis results, 
usually associated with emphysema. Bronchiectasis is essentially a dis- 
ease of adult life, but at times is found in infants even at birth. This 
congenital bronchiectasis, in which numerous cysts containing a thin 
liquid are found, usually in one lung, is regarded as the result of syphilis, 
although it is probable that in certain instances it represents irregulari- 
ties of development from unknown causes. 

4G 



722 



DISEASES OF THE RESPIRATORY APPARATUS. 



Morbid Anatomy. — Bronchiectasis generally affects bronchi of me- 
dium size and their smaller branches, and the alterations may be present 
throughout both lungs, in which case the lower lobes are more likely to 
be especially affected. They are oftenest limited, however, to one lung, 
perhaps to a single lobe. The dilatation is uniform, cylindrical, or cir- 
cumscribed (fusiform or saccular), the fusiform dilatations often being 
varicose from the alternation of dilated portions with those of relatively 
normal calibre. As a result of the dilatation, the diameter of the affected 
portion of the bronchial tube is variously increased, and in saccular dila- 
tation numerous cavities of various size are formed along the course of 
the bronchus. The cavities may be blind from the obliteration of out- 
going branches, and the connection with the main trunk is also some- 
times destroyed. Isolated cavities of bronchial origin thus are formed in 
the lungs. Neighboring cavities may become confluent from absorption 
of the lung-tissue, giving rise to trabeculated sacs as large as the fist. 
Dilatation of the smaller bronchi is often made evident by the ease with 
which their course is followed with the scissors. The wall of the dilated 
bronchus is either hypertrophied or atrophied, the two conditions not 
infrequently occurring in different parts of the same lung. The hyper- 
trophied mucous membrane is thickened, sometimes corrugated, perhaps 
covered with villi, and of a dark- red color from the presence of numerous 
dilated blood-vessels. When atrophied, the wall is thin, smooth, and 
shining, often not sharply defined from the surrounding lung- tissue. As 
the wall of the bronchus becomes thin the epithelium is flattened, the 
cartilage is absorbed, the muscular tissue and elastic fibres in part dis- 
appear and in part are widely separated. The peribronchial tissue be- 
comes thickened and fibrous. The dilated bronchi contain thin, opaque 
gray, muco-purulent fluid ; in the sacculi is a denser secretion, which 
may be an opaque gray mucus or inspissated caseous material, sometimes 
infiltrated with lime salts. If the contents are inspissated the wall is 
usually thickened and contracted, indicating a tendency to obliteration 
of the cavity. Saccular dilatations which are entirely disconnected from 
the bronchus from which they originate may appear as cysts containing 
a clear fluid. Ulceration of the wall is rare, but may occur, especially 
when the contents of the dilated bronchus are retained and become 
putrid. Gangrene of the wall then may result and extend to the neigh- 
boring lung-tissue. 

Symptoms. — For a long time the symptoms and signs of bronchiec- 
tasis are those of chronic bronchitis, and are not likely to suggest dilata- 
tion of the bronchi unless localized at some particular part of the lung. 
The symptom which is especially characteristic of bronchiectasis is cough 
occurring in paroxysms and followed by the ejection of a large quantity 
of sputum. The cough usually occurs in the morning, and not infre- 
quently is induced by a change of position, as perhaps in turning from 
one side to the other, or in assuming the upright position after a night's 



DISEASES OF THE NOSE, EARYNX, TRACHEA, AND BRONCHI. 723 

rest. More than twenty ounces of secretion may be raised from the 
lungs in twenty-four hours. When allowed to settle it is usually thin, of 
a dirty- gray color, and frequently is of a disagreeable odor, which in cer- 
tain cases is distinctly putrid. A sediment is formed also composed of 
pus- corpuscles, with which are small grayish particles containing fattily 
degenerated cells, crystals of fat acids, numerous red blood-corpuscles, 
and bacteria ; hsematoidin crystals also are sometimes present. The 
upper layer is a thin liquid covered with a brownish froth. In diffused 
bronchiectasis the physical signs are those of a chronic bronchitis, while 
in circumscribed bronchiectasis they are those of a cavity, manifested 
by amphoric resonance, cavernous breathing, and coarse gurgling rales, 
alternating with dulness and feeble or absent respiration in the same 
place according as the cavity is full or empty. 

After many years there is likely to be progressively increasing dys- 
pncea, aggravated on slight exertion, and then associated with cyanosis. 
The finger-tips are clubbed, the hypertrophic osteoarthropathy of Marie, as 
in chronic tuberculosis and in obstruction to the pulmonary circulation 
from cardiac disease. The diagnosis is based upon the peculiarities of 
the cough and expectoration and their occurrence for a long time without 
other symptoms. It is certain only when the signs of a cavity are present. 
In such cases tuberculosis is eliminated by the absence of bacilli, gan- 
grene by the history and the absence of shreds of lung-tissue, and abscess 
by lack of evidence of antecedent pneumonia. If the signs of a cavity 
are absent, bronchiectasis may be overlooked. 

The prognosis is usually favorable as to length of life, but death may 
suddenly occur from haemoptysis, or rapidly from gangrene of the lung if 
the secretion becomes putrid. As a rule, diffused bronchiectasis is event- 
ually complicated with emphysema, dilatation of the heart, and cardiac 
incompetency, with their symptoms and result. In other cases, in the 
course of years the patient becomes weak and thin from the persistent 
cough accompanied eventually by continued fever, the symptoms being 
those of a pulmonary phthisis. 

Treatment. — There is no known method of reducing bronchial 
dilatation. The administration both by the mouth and by inhalation of 
terebene and various volatile oils, especially of sandal wood or of creo- 
sote, sometimes is effective in checking excessive secretion. Osier recom- 
mends that with a suitable syringe there be introduced into the trachea 
twice a day a drachm of a solution of ten parts of menthol and two 
parts of guaiacol in eighty-eight parts of olive oil. When the cavity is 
situated near the surface of the lung it may sometimes be advantageously 
opened through the chest-wall and drained. 

BRONCHIAL OBSTRUCTION. 

Obstruction of the trachea and bronchi may result from external or 
internal causes. The common external cause is pressure from tumors, 



724 



DISEASES OE THE RESPIRATORY APPARATUS. 



especially those of tlie thyroid, and of the cervical and mediastinal 
lymph-glands, and anenrism of the arch of the aorta. Cancer of the 
oesophagus, vertebral and intra-pulinonary tumors, abscess of the medi- 
astinum, enlargement of the heart, and pericardial exudation also may 
produce pressure from without. The internal causes of obstruction in- 
clude foreign bodies, membranous exudations from acute inflammation, 
and strictures from chronic inflammation or syphilis and tumors. 

In obstruction of the trachea there is a sense of constriction in the 
region affected, with difficulty of breathing, especially of inspiration, 
which is prolonged and perhaps harsh. According to the degree of 
obstruction is the severity of the dyspnoea, which may become so great 
as to be associated with conspicuous action of the accessory muscles of 
respiration, although the larynx changes its position but little. 

Bronchial obstruction is generally unilateral, and the result depends 
upon the size of the bronchus obstructed and the degree of the obstruc- 
tion. The symptoms of obstruction of a small bronchus may be those 
of a localized bronchitis. If a large tube is obstructed, the air is both 
admitted and expelled with difficulty, inspiration being more interfered 
with than expiration. If the obstruction is complete, atelectasis results, 
and there is shrinkage of the corresponding half of the chest, with com- 
pensatory emphysema of the other lung and corresponding distention 
of that half of the thorax. Prominence of the cervical muscles and re- 
traction of the supraclavicular and intercostal spaces and of the lower 
ribs indicate the severity of the dyspnoea. In the region of incomplete 
obstruction sonorous rales are to be heard, and may be recognized on 
palpation of the chest. The respiratory murmur is feeble or absent 
in the region supplied by the obstructed bronchus, and is exaggerated 
elsewhere. 

Prognosis. — The prognosis depends upon the nature and the cause 
of the obstruction, which may be such as early to cause death, or in case 
of the obstruction of a small or medium-sized bronchus may be directly 
recovered from, although bronchiectasis and emphysema may perma- 
nently result. 

Treatment. — When the bronchial obstruction is due to a tumor, this, 
if possible, should be removed ; foreign bodies may be coughed up, but if 
they can be located, by the Eontgen rays or otherwise, they call for surgi- 
cal interference. Medical treatment should be advised in case of enlarge- 
ment of the thyroid or of mediastinal lymphomata, as recommended in 
the articles on these subjects. The appropriate treatment for syphilis 
should be used when this disease is suspected as a cause of the obstruc- 
tion. If the exudation of pericarditis is sufficiently large to produce 
symptoms of obstruction, it may be removed by paracentesis. The 
dyspnoea from inoperable or incurable causes of obstruction is to be 
relieved by inhalations of oxygen or by the administration of codeine or 
morphine. 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 725 



ASTHMA. BRONCHIAL ASTHMA. 

Definition. — A functional disturbance of the respiratory apparatus 
manifested by sudden attacks of dyspnoea, with intervals of comparative 
freedom. Expiration is more interfered with than inspiration, and the 
sputum is usually characteristic. 

The term asthma is used often to include various spasmodic affections 
of respiration, especially the attacks of dyspnoea occurring in larjmgitis 
or in consequence of the pressure of tumors in the vicinity of the trachea 
and bronchi, e.g., so-called thyroid asthma and thymic asthma. Attacks 
of dyspnoea occurring in disease of the heart or blood-vessels are usu- 
ally designated cardiac asthma ; these, and the probably closely allied 
uraemic dyspnoea, so-called renal asthma, and the attacks of dyspnoea in 
hysteria often due to spasm of the diaphragm and sometimes termed 
asthma, are to be regarded as symptoms of the diseases in which they 
occur, the disease asthma being limited to the peculiar paroxysms of 
disturbed breathing excited more especially by conditions limited to 
the respiratory tract. Although it is asserted that the dyspnoea is due 
usually to spasm of the involuntary muscles in the bronchial wall, it is 
urged also that a congestive swelling of the bronchial mucous membrane 
may occur and mechanically disturb breathing. Probably of especial 
importance as a mechanical cause of the dyspnoea is the peculiar material 
expelled towards the end of the attack and regarded as casts of the 
bronchioles. 

Etiology. — The sensitiveness of the nervous apparatus which makes 
the patient liable to attacks of asthma is considered to be often congeni- 
tal, since asthma frequently occurs in certain families, especially those in 
which neurasthenia, hysteria, epilepsy, neuralgia, and gout are common. 
It is observed that asthma not infrequently occurs in persons suffering 
from saccharine diabetes and lead poisoning. Bronchial asthma may be 
present at all periods of life, but more frequently in the adult, and is 
found in men oftener than in women. Of late years especial importance 
has been directed to the presence of local disease of the respiratory 
mucous membrane, especially in the nose, pharynx, and larynx, as favor- 
ing the production of asthma. 

The immediate cause of the attack is often a direct or reflex irritation 
of the nerves of respiration, especially the branches of the pneumogastric 
nerve. The exciting causes appear to be intimately connected with climate. 
Residence in a given locality may be helpful to the one and injurious to 
the other. The influence of climate does not depend upon the degree of 
moisture or the range of temperature, but oftener upon peculiarities of 
the individual, since a moist climate and cold weather are beneficial to 
some and injurious to others. Attacks of asthma are frequently brought 
on by the direct inhalation of irritating particles, whether as dust or as 
odors from flowers or even animals. In certain cases the attack of asthma 



726 



DISEASES OF THE RESPIRATORY APPARATUS. 



is regarded as the result of a reflex irritation of the nerves of respiration 
from disease of the stomach or of the intestinal tract, hence dyspeptic or 
nervous asthma, or from the pelvic organs, and even in consequence of 
pregnancy, hence uterine asthma. 

Symptoms. — Asthma is a disease of gradual development, and there is 
nothing suggestive of this affection until the occurrence of a paroxysm 
of dyspnoea. The existence of a sensitive respiratory mucous membrane 
is indicated often by the frequent occurrence of attacks of bronchitis, and 
there may be occasionally a sense of thoracic constriction. The imme- 
diate asthmatic attack usually takes place at night, and is sometimes 
preceded for several hours by a sense of substernal constriction, frontal 
headache, or digestive disturbance. The patient is roused from a sound 
sleep with a sense of suffocation. He sits upright, and breathes violently, 
but not with increased frequency, the inspirations usually being short 
and deep and the expirations prolonged. In other cases inspiration may 
be relatively easy and expiration especially labored. The respiration is 
noisy from the numerous sonorous and sibilant rales which are to be heard 
even at a remote distance from the patient. The accessory muscles of 
respiration are firmly contracted, the chest is fully expanded, and the 
patient leans forward, sits astride a chair, or by other change of position 
endeavors to expand the chest to its utmost. As the dyspnoea increases, 
the face is at first red, then of a bluish tint, and finally pale ; the skin is 
cool, there is profuse sweating, and the pulse becomes rapid and weak. 
There is increased resonance on percussion, from excessive distention 
of the lungs, which overlap the heart and depress the diaphragm. On 
auscultation coarse and fine musical rales are to be heard throughout 
the chest both on inspiration and on expiration, more abundantly during 
the latter. The attack of dyspnoea continues for minutes or hours, relief 
often being experienced by the expulsion of a characteristic sputum. 
The cough is at first slight and dry, but becomes paroxysmal and forcible 
in the efforts to raise secretion, the presence of which in the lungs is often 
made evident by the substitution of moist for dry rales. The sputum is 
viscid, grayish white, scanty, or profuse, and contains the spiral threads 
discovered by Curschmann. Some of these may be large enough to be 
seen with the naked eye, while others require the use of the lens. When 
the fibres are examined with the microscope they are found to be com- 
posed of a gelatinous mass twisted about a homogeneous, usually trans- 
lucent, central thread. The spiral fibres contain mucin, and in the 
sputum are also alveolar epithelium, eosinophiles, and Charcot crystals, 
the latter increasing in number the longer the sputum is exposed to the 
air. 

The attack usually lasts several hours, but may terminate in the course 
of minutes, and the severest attacks may last for days. As the breathing 
becomes easier the patient feels exhausted, falls asleep, and awakes ap- 
parently well, at the most somewhat fatigued. Other attacks are likely 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 727 

to occur in the course of successive days or at intervals of a number of 
days, during which there is more or less cough and even characteristic 
sputum between the attacks. Longer or shorter intervals of freedom, 
lasting months or years, may then follow, or the attacks are of such 
frequent occurrence that pulmonary emphysema and eventual dilatation 
of the heart result. 

Diagnosis. — Expiratory dyspnoea affecting both lungs is an important 
characteristic of bronchial asthma, by means of which other causes of re- 
current attacks of dyspnoea, except in emphysema, chronic bronchitis, 
and cardiac asthma, may be excluded. In emphysema the physical ex- 
amination of the chest and the persistence of dyspnoea are sufficiently 
distinctive. In cardiac asthma the dyspnoea affects both inspiration 
and expiration. Bales are absent unless pulmonary oedema occurs as a 
complication. The discovery of Ourschmann's spirals in the sputum at 
the close of* an attack of dyspnoea is to be made practically only in 
bronchial asthma. 

Prognosis. — Asthma, except when it occurs in childhood, is usually a 
disease lasting for years, and in the bronchial asthma of adults permanent- 
recovery is rare unless the cause is remediable or the patient is able to 
find and permanently reside in a climate in which he is free from the 
attacks. The usual termination of this disease is in emphysema and 
chronic bronchitis, manifested by persistent dyspnoea, chronic cough, 
abundant muco-purulent sputum, and an hypertrophied right ventricle, 
which tends to become incompetent with resulting cyanosis and dropsy. 
In such cases attacks of bronchial asthma may be replaced by those of 
cardiac asthma, in which inspiration and expiration are alike affected and 
the physical signs are those of oedema of the lungs. 

Treatment. — The treatment of a case of asthma naturally divides 
itself into the management of the case between and during the paroxysms. 
As the attacks sometimes depend upon a removable cause, especially 
upon the presence of polypi or other obstructive lesions of the nose, a 
careful search for such cause should be made, followed, if opportunity 
offer, by removal. The urine also should always be examined, to pre- 
vent the overlooking of a ursemic origin. As it is probable that in 
many cases the disease depends, in part, at least, upon an excessive sus- 
ceptibility of the mucous membranes of the lung to catarrhal inflamma- 
tion, and as in old cases there is almost always more or less complicating 
chronic bronchitis, the treatment of chronic bronchitis, especially its 
climatic treatment, is often very important. Further, in many cases 
without obvious bronchial catarrh, asthma may be modified by climatic 
surroundings, so that when it is possible residence in a warm, usually 
moist, climate should be secured. In scarcely any other disease, how- 
ever, is it so essential to study the individual characteristics in each 
case, as at present the relations of asthmatic attacks to climate and 
locality are entirely inexplicable. As an example, we may mention the 



728 



DISEASES OF THE RESPIRATORY APPARATUS. 



case of a great traveller and sufferer from the disease who found freedom 
from asthma only in the city of Caracas. To some cases the sea-shore, 
to others the mountains, afford relief ; some do best in the city, others 
in the country ; occasionally change of rooms in the house affects the 
number and violence of the attacks 5 not rarely sleeping upon feathers 
or a feather pillow will provoke asthmatic symptoms. 

The general hygienic management should be that of chronic bronchial 
catarrh, though, especially in children, some importance may be attached 
to restricting the use of meat or other highly nitrogenous foods. 

~No diet, however, which produces indigestion or flatulence is suit- 
able for the asthmatic. If an almost purely meat diet is the only one 
digested, it should be the only one allowed. Further, the heavy meal 
should always be taken in the middle of the day, and the supper should 
be made very light, so that the digestion may be completed by bedtime. 

In some cases of asthma the continuous use of small doses of arsenic 
for months has pronounced effect. More generally useful is potassium 
iodide, which should be given for three months in ascending doses up 
to the point of tolerance. The beneficial effects in the prevention of 
attacks which sometimes follow the use of grindelia robusta and other 
balsamic expectorants are probably due to the relief of complicating 
catarrhs. At times the continuous administration of the bromides, 
especially of ammonium bromide, with antipyrin or other of the allied 
chemical drugs, is very useful in lessening the susceptibility of the 
nervous system. The inhalation of compressed air in the pneumatic 
cabinet is highly spoken of by some writers. 

The remedies which are employed during the paroxysm of asthma 
are numerous. A hypodermic injection of morphine and atropine or the 
inhalation of a little ether or chloroform sometimes will abort an attack, 
but in the use of these agents the danger of the formation of a drug 
habit is a very important consideration. The most generally useful 
remedies are the group of vegetable drugs which contain atropine and 
its allied alkaloids, — namely, stramonium of various species, belladonna, 
and hyoscyamus. These drugs have the power of paralyzing the motor 
nerves, and hence act much more favorably in asthmatic or other spasm 
when applied locally. For this reason they are most effectively used 
in asthma by means of smoking. For some unknown reason the fumes 
produced by the burning of potassium nitrate have a most soothing effect 
upon many asthmatics, and the addition of this salt to the powdered 
stramonium or other allied herb makes it burn much more steadily and 
rapidly and at the same time increases the efficacy of the fumes. (See 
formula 15. ) The numerous proprietary powders used in asthma, often 
with great relief, usually contain a delirifacient herb and the potassium 
salt. The addition of arsenic still further increases the efficiency of the 
mixture. (See formula 18.) 

The nitrites, especially amyl nitrite taken by inhalation, are exceed- 



DISEASES OF THE NOSE, LARYNX, TRACHEA, AND BRONCHI. 729 

ingly effective in the height of a paroxysm, but are very apt soon to lose 
their power. The inhalation of chloroform or of ether will sometimes 
immediately cnt short an attack. Pyridin has been strongly recom- 
mended by Germain See and others, the fumes of half a drachm to a 
drachm exposed in a saucer being inhaled. An old remedy, which is 
especially effective when the asthma is complicated with subacute bron- 
chitis, is tincture of lobelia, which may be taken through the day or 
at the time of the attack in doses of fifteen drops of the tincture every 
twenty minutes until it causes vomiting. Chloral often acts well. Hoff- 
mann's anodyne is sometimes of service. Counter-irritation by means 
of mustard plasters over the whole chest is sometimes serviceable. 



730 



DISEASES OF THE RESPIRATORY APPARATUS. 



CHAPTEB II. 

DISEASES OF THE LUNGS. 
CONGESTION OF THE LUNGS. 

An increased quantity of blood may be present either throughout the 
iungs or in limited portions of them. It occurs under a variety of condi- 
tions, and is either transitory or persistent. The distinction is drawn 
usually between active and passive congestion, the former being attrib- 
uted to the presence of an increased quantity of blood in the arteries, 
while passive congestion is the result of an obstruction to the outflow of 
blood from the lungs. 

Active congestion of the lungs may result from prolonged and violent 
muscular effort, as in running or rowing, in which the action of the heart 
is excessively increased, or may be caused by a rarefied atmosphere, as in 
mountain- climbing or balloon-ascensions. It may be due to the inhala- 
tion of hot air or other irritants, and to the virus of pneumonia, influenza, 
and tuberculosis. Acute congestion of the lung sometimes follows the 
rapid withdrawal of a large quantity of fluid from the chest in pleu- 
risy. An arterial congestion of the lung has been caused by affec- 
tions of the brain, especially at the base, and in unilateral cerebral 
lesions the pulmonary congestion has been found on the opposite side of 
the body. The congestion is called compensatory or collateral when the 
other lung is prevented from receiving a normal quantity of blood by 
pressure from without, as in pleurisy or from tumors, or by pressure 
from within, as in pneumonia, or by embolism of the pulmonary artery. 
Congestion, perhaps collateral, usually occurs in acute miliary tubercu- 
losis of the lung. 

In rapid and general congestion of the lungs there are extreme dys- 
pnoea and a bloody, frothy sputum. Death may occur instantaneously, as 
in pulmonary embolism or during violent muscular effort, in which case 
the lungs are excessively distended, and of a dark-red color throughout, 
and frothy blood escapes from the cut surface. In general, however, 
the pulmonary congestion is to be regarded as a complication of the 
disease in which it is present, and is insufficient to produce serious dis- 
turbance. 

Passive congestion of the lungs is either general or partial. When gen- 
eral it is the result of causes preventing the escape of blood from the 
lung, especially obstruction to the flow through the heart in consequence 
of stenosis of the valve or weakness of the parietes. Passive pulmonary 
congestion follows also obstruction to the venous outflow by intra-thoracic 
tumors. 



DISEASES OF THE LUNGS. 



731 



General passive congestion of the lungs is usually slowly progres- 
sive, and they become distended, heavy, resistant, and of a dark reddish- 
brown color, which on exposure to the air resembles that of iron rust. 
The cut surface is relatively dry. To this condition of the lungs the 
term brown induration is given. Microscopic examination shows that the 
distended capillaries project far into the alveoli, the interstitial tissue 
is somewhat increased in quantity and abundantly pigmented, and the 
alveoli contain large epithelial cells in which are red blood- corpuscles 
and granules of blood-pigment. 

Brown induration of the lung gives rise to no especial symptoms while 
the heart is capable of performing its work. With failing compensation 
dyspnoea, cough, and a sputum containing blood- corpuscles and blood- 
pigment are likely to result. 

Hypostatic congestion is used to designate partial passive congestion of 
the lungs which results from an enfeebled action of the heart combined 
with the persistence of the body in a definite position. It therefore 
occurs in those affections in which these causes are oftenest associated. 
Hypostatic congestion is to be expected in prolonged severe infectious 
diseases, especially typhoid fever and acute articular rheumatism. It 
is to be found in prolonged coma, as from cerebral hemorrhage, and 
is likely to occur in the profound weakness due to extensive loss of 
blood. The condition is also to be observed in extreme distention of the 
abdomen from liquid, gas, or tumors. The dependent parts of the lungs 
or of a lung, according to the position which the patient has long held, 
are of a dark-purple color, are heavy, and contain but little air. The 
blood-vessels are injected, and there is blood in the alveoli. In extreme 
cases the cut surface resembles that of the spleen, — splenization, — the 
affected part of the lung is easily torn, and on pressure a thick, bloody 
fluid escapes. The splenified lung readily becomes inflamed, in which 
case the condition is known as hypostatic pneumonia. 

There are no symptoms especially characteristic of hypostatic con- 
gestion, the associated feebleness of the respiration and of the pulse being 
symptoms to be expected in the affections giving rise to the congestion. 
Careful physical examination is likely to show a slight diminution of 
resonance in the dependent parts of the chest, feeble or bronchial breath- 
ing, and fine moist rales, slowly advancing along the line of gravity. 
Commonly the condition of the patient is such that physical exami- 
nation of the chest is inadvisable. 

Treatment. — The treatment of congestion of the lungs is usually 
that of the condition which produces it. If it be from heart-failure it is 
to be met by powerful cardiac stimulants, aided by counter-irritation 
with turpentine stupes or similar quickly acting powerful rubefacients, 
or with dry cups all over the back. The cases of cardiac disease in 
which the intensest pulmonary engorgement exists represent those which 
are spoken of on page 674, in which free venesection affords the only 



732 



DISEASES OF THE RESPIRATORY APPARATUS. 



means of relief, and in which, if the blood cannot be obtained otherwise, 
even aspiration of the right anricle may be justifiable. 

In the hypostatic congestion of typhoid or other low fevers, in addi- 
tion to the use of alcohol, digitalis, and other cardiac stimulants, and of 
free counter-irritation, the exhibition of large doses of ergot (to tone up 
the pulmonic blood-vessels) and of terebinthinate expectorants (oil of 
turpentine and terebene) is sometimes advantageous. 

When the pulmonic congestion is due to a narcotic poisoning, as 
with morphine, active artificial respiration, or, better, so-called ' ' forced 
respiration," affords the best chance of recovery. 

Active congestion of the lungs, if it really exists, is to be treated, 
like the first stages of pneumonia, by the use of venesection or local 
bleeding and of cardiac sedatives, — especially veratrum viride. 

PULMONARY HEMORRHAGE. 

Hemorrhage occurs from the large as well as from the small blood- 
vessels of the lung, and may be also the result of the rupture of an aneu- 
rism of the aorta into the lung. When large pulmonary vessels are the 
source of hemorrhage the rupture is usually due to a weakening, perhaps 
aneurismal dilatation, of the arteries of the walls of phthisical cavities. 
As a rule, the bleeding comes from small vessels, especially of the con- 
gested mucous membrane in bronchitis or from the alveolar capillaries in 
acute congestion and in pneumonia. Pulmonary hemorrhage also occurs 
in gangrene, abscess, and cancer of the lung, in pulmonary embolism, in 
chronic passive congestion, and in purpura. A periodical pulmonary 
hemorrhage has been observed rarely in women with amenorrhcea, and is 
regarded as vicarious. Pulmonary hemorrhages connected with disease 
at the base of the brain are considered to be of vaso-motor origin, and if 
the lesion is on one side of the brain the pulmonary hemorrhage may be 
found in the lung of the opposite side of the body. The blood is to be 
found in the lung as clots in the larger bronchi, or as specks or streaks, 
due to the inhalation of blood into the bronchioles and alveoli. A pul- 
monary cavity may be distended with a mass of clotted blood, and in 
hemorrhage complicating intra-cranial disease circumscribed rounded 
masses of hemorrhagic infiltration perhaps as large as the fist may be 
present. Haemoptysis is the symptom significant of pulmonary hemor- 
rhage, although profuse and even fatal bleeding into the lungs may take 
place without the spitting of blood. Haemoptysis is generally imme- 
diately preceded by a slight irritative cough or by a tickling sensation 
in the larynx. The mouth is then suddenly filled with a liquid having a 
saltish or slightly astringent taste and proving to be blood. In severe 
cases of pulmonary hemorrhage, as from the rupture of an aneurism, the 
flow of blood may be so rapid that in a few minutes a pint or more of 
almost pure red blood escapes. Usually a few or several mouthfuls, in all 
less than an ounce, of blood are ejected, and the blood is bright red and 



DISEASES OF THE LUNGS. 



733 



frothy. For several days after the attack of haemoptysis dark blood 
intimately mixed with mucus is occasionally coughed up. In the first 
attack of haemoptysis the patient, as a rule, appears anxious, and, if 
the hemorrhage is profuse, collapse rapidly follows, the pulse becoming 
feeble and the skin cool and moist. 

Pulmonary hemorrhage is rarely immediately dangerous unless copious 
in advanced tuberculosis or from a ruptured aneurism. Death then 
results in part from the loss of blood, in part from suffocation in conse- 
quence of obstruction of the bronchial tubes by the inhalation of blood. 
Commonly the hemorrhage ceases quickly, the amount of blood lost being 
insufficient to produce anaemia. Slight attacks of hemorrhage, especially 
in tuberculosis, are of frequent occurrence, and the patient becomes so 
accustomed to haemoptysis as to be but little disturbed by this symp- 
tom. Indeed, not infrequently it affords temporary relief to a sense of 
constriction localized in the chest. Haemoptysis is to be distinguished 
from haematemesis, since it is associated rather with coughing than with 
vomiting, and the blood is liquid, red, and frothy, not clotted, dark, or 
resembling coffee-grounds. The physical examination of the lungs when 
tuberculosis is suspected as the cause of pulmonary hemorrhage should 
be postponed until the cessation of the bleeding, lest a recurrent attack 
should be occasioned thereby. Attacks of haemoptysis are sometimes 
feigned to excite sympathy or for other purposes, but the microscopical 
examination of the red fluid then fails to disclose blood- corpuscles, and 
the physical examination of the respiratory tract and the history of the 
case give no evidence of the usual causes of pulmonary hemorrhage. 

The treatment of haemoptysis is sufficiently considered in the articles 
on Tuberculosis (page 298) and on Chronic Heart Disease (page 676). 

THROMBOSIS AND EMBOLISM. 

Branches of the pulmonary artery may become obstructed rarely by 
thrombi, which sometimes originate in the vessel in consequence of disease 
of its wall or from pressure upon it. The usual cause of obstruction of 
the pulmonary artery is an embolus composed of clotted blood and brought 
in the circulating blood either from the right side of the heart or from the 
systemic veins of the body, especially from the pelvic plexus and from 
the veins of the legs. The embolus may be so large as to obstruct the 
pulmonary artery at its origin, but is usually of such size as to enter 
an intra-pulmonary branch. Its arrest at any particular point is followed 
by a stoppage of the direct arterial flow into the region supplied by the 
obstructed vessel and by extreme congestion of the part, ending in hem- 
orrhage, through the collateral circulation. There result in consequence 
the familiar appearances of hemorrhagic infarction, single or multiple, 
according to the number of emboli. Wedge-shaped masses are formed, 
the base usually represented by the pleura, of the size of beech-nuts or 
Brazil nuts, and in extreme cases composing an entire lobe of the lung. 



734 



DISEASES OE THE RESPIRATORY APPARATUS. 



They are of a dark-red color, dense, relatively dry on section, and free 
from air. In the later stage of the infarction the nodule becomes paler in 
color and softer in consistency, and absorption of the extravasated blood 
is possible. If the embolus comes from a septic thrombus, abscess results, 
a septic pleurisy being the usual complication. A similar termination at 
times occurs in bland embolism, from the presence of bacteria upon the 
respiratory surface within the region of infarction. 

The symptoms of pulmonary embolism depend upon the size of the 
artery obstructed. If a small branch only of the pulmonary artery is 
concerned, there may be little or no disturbance. When larger branches 
are affected, respiration is usually temporarily increased. There may be 
a chill, although there is but little subsequent fever, except in septic em- 
bolism. There is slight cough, followed sooner or later by bloody expec- 
toration in small quantities and lasting several days. If the infarction 
extends to the pleura, localized pain occurs. In small infarctions, or 
in those situated centrally, the physical signs are usually negative. In 
large infarctions, circumscribed dulness and friction, feeble or bronchial 
breathing, and moist rales are to be expected. When the embolus is 
large enough to obstruct the trunk of the pulmonary artery there are 
sudden extreme dyspnoea, the admission of air into the lungs being un- 
obstructed, cough, thoracic pain, lividity or pallor, rapidly failing pulse, 
cold sweats, intense anxiety, and attacks of fainting or unconsciousness, 
with or without spasms, and death occurs in the course of a few minutes 
or within an hour or two. 

The diagnosis of embolic infarction is based upon the sudden and un- 
expected occurrence of dyspnoea, the air- tubes being open, followed by 
cough and occasional hemorrhagic sputa for several days, in a person in 
whom the condition of the heart or of the systemic veins is such as to 
permit the presence of a thrombus. 

Treatment. — There is no special treatment for pulmonic emboli or 
thrombi. Opium should be given as required to quiet nervous distress, 
and symptoms, as far as may be, should be met as they arise. 

(EDEMA OF THE LUNGS. 

CEdema occurs in the lungs, as elsewhere, in consequence of active or 
passive disturbances of the circulation or of increased porosity of the wall 
of the blood-vessels from affections of nutrition or of innervation. It is, 
therefore, to be found in diseases in which modifications of pulmonary 
circulation are present and in those in which general dropsy is conspicu- 
ous, as acute and chronic nephritis, cardiac disease, and various chronic 
diseases in which anaemia and impairment of nutrition are prominent. In 
these as in other affections, even those of acute nature, diffuse or circum- 
scribed oedema of the lungs may occur at the close of life and be the 
immediate cause of death. Diffuse pulmonary oedema sometimes takes 
place in consequence of acute pulmonary congestion following embolism 



DISEASES OF THE LUNGS. 



735 



of the trunk of the pulmonary artery or the rapid removal of a large 
quantity of fluid from the pleural cavity. More frequently it is the result 
of obstructed venous outflow, and is best explained by Welch's investiga- 
tions, which show that a paralyzed left ventricle prevents the escape of 
blood from the pulmonary veins in sufficient quantity to make room for 
that entering from the right ventricle. Capillary engorgement, followed 
by the transudation of serum and red blood- corpuscles, is the result. In 
circumscribed oedema the transudation of fluid is dependent upon local 
as well as upon general causes. If gravity determines the position of the 
fluid, the oedema is called hypostatic. In atelectasis the affected portion 
of the lung becomes eedematous in consequence of the localized bronchial 
obstruction and pulmonary congestion, and in collateral oedema the fluid is 
accumulated in the vicinity of a congested or inflamed portion of the lung, 
and frequently represents an inflammatory exudation. 

In oedema of the lungs the effusion from the blood-vessels accumulates 
in the alveoli and in the interstitial tissue. The affected portion of the 
lung is distended, dense, heavy, pitting on pressure, and slightly crepitant. 
It is gray, or reddish gray, and more or less translucent according to the 
quantity of blood present and the degree of the oedema. On section of 
the lung abundant fluid is to be squeezed from the eedematous portion, 
and is the more frothy the more acute the oedema. In chronic pulmonary 
oedema the fluid contains fewer air-bubbles and more red blood-corpuscles, 
and the lung-tissue is easily torn. Chronic oedema of the lungs is so inti- 
mately associated with chronic congestion, desquamation from the alve- 
olar walls, and the presence of inflammatory irritants, and even of an 
inflammatory exudation, that the distinction between chronic oedema, 
chronic passive congestion, and desquamative or catarrhal pneumonia 
is often arbitrary. 

The symptoms of oedema are generally of slow onset, and present but 
little that is characteristic until there are a sense of more or less suffoca- 
tion, increasing difficulty of breathing, perhaps associated with cyanosis, 
a short, dry cough, and a weak pulse. If the oedema occurs rapidly, as 
in severe pulmonary embolism or thoracentesis, there may be violent dys- 
pnoea and abundant, frothy, perhaps hemorrhagic, sputa. On physical 
examination of the eedematous portion of the lung there is dulness, the 
extent and intensity of which depend upon the quantity of fluid present, 
and the dulness is often comparatively slight, especially in acute oedema. 
The respiratory sounds are enfeebled, and abundant fine moist rales are 
to be heard. 

Diffuse oedema of the lungs is a condition of serious import, since 
it usually represents a terminal stage in the disease of which it is a 
symptom. 

Treatment. — The treatment of oedema of the lungs is that of the 
renal or other condition which produces the attack, with the addition 
of very active counter- irritation by means of turpentine stupes or of dry 



736 



DISEASES OF THE RESPIRATORY APPARATUS. 



cups used freely, and the exhibition, as a rule, of large doses of strych- 
nine and other respiratory stimulants hypodermically. In a large pro- 
portion of cases cardiac stimulants are urgently required ; digitalis and 
ether may he used subcutaneously, whilst alcohol, musk, camphor, or 
Hoffmann' s anodyne is given freely by the mouth. In some sthenic cases 
wet cupping, or even venesection, may be practised with advantage. In 
urseniic cases with secondary cardiac weakness it must not be forgotten 
that the hot bath — either the Turkish, the Eussian, or the simple water 
bath — is dangerous, and that even pilocarpine given hypodermically 
may increase the difficulty by increasing the intra-pulmonic exudation. 
Great caution is, therefore, necessary in the use of active diaphoretics or 
diaphoretic measures. The vapor bath, so applied that the patient does 
not breathe the hot air, is probably the safest and most efficient diapho- 
retic procedure in these cases. In most cases of oedema of the lungs free 
serous purging is of great advantage. 

ATELECTASIS. 

Definition. — An incomplete dilatation of the alveoli and a total or 
partial lack of air in them. 

Etiology. — The immediate cause of atelectasis is obstruction to the 
admission of air in consequence of the inability of the lungs to expand, 
or of a mechanical obstruction in the air-passages. The distinction is 
usually drawn between congenital and acquired atelectasis. In congenital 
or fcetal atelectasis the affected portions of the lungs fail to expand, either 
in consequence of weakness of the infant from disease or premature birth, 
or from obstruction of the air-passages by foreign material, strangulation, 
or an abdominal tumor. In acquired atelectasis the air is prevented from 
entering the alveoli in part because of weakness from severe disease, but 
particularly from obstruction of the bronchi in consequence of inflam- 
mation of the mucous membrane, especially when the smaller tubes are 
concerned, as in capillary bronchitis, or in measles, whooping-cough, and 
diphtheria. The entrance of air into the alveoli is prevented also by 
compression of the lung from the presence of liquid or gas in the pleural 
or pericardial cavity, from intra- thoracic tumors, and from extreme curva- 
ture of the spine. Excessive quantities of liquid or gas or large tumors 
in the abdominal cavity, by opposing the descent of the diaphragm, 
likewise interfere with the admission of air into the lungs. According to 
the causes, acquired atelectasis may thus be divided into atelectasis from 
obstruction and atelectasis from compression. 

Morbid Anatomy. — In foetal atelectasis the posterior and lower por- 
tions of the lung are usually affected, and the lobules into which the air 
has failed to enter appear as dense, dark-blue, solid, more or less wedge- 
shaped nodules, depressed beneath the pleura. The cut surface is smooth, 
and but little blood escapes on pressure. In acquired atelectasis the air 
is removed from the affected portions of the lungs in part by the 



DISEASES OF THE LUNGS. 



737 



contraction of the elastic tissue, in part by absorption, and in part by 
compression of the surface. According to the resulting appearances, the 
distinction is drawn between the collapsed and the compressed lung. The 
collapsed portions of the lung are few or many, more or less wedge-shaped, 
of a bluish slate color as seen depressed beneath the pleural surface ; they 
are dense, airless, non- crepitant, and are smooth on section. The lobules 
concerned and those in foetal atelectasis can be artificially inflated. In 
the course of time the atelectatic portion of the lung becomes distended 
by the passage into the alveoli of the liquid and solid constituents of the 
blood-vessels, and by the desquamation of epithelium from the alveolar 
wall. The cut surface somewhat resembles that of the spleen : hence the 
appearances at this stage, as in hypostatic congestion, are designated 
splenization, and somewhat simulate those of lobular pneumonia, which 
eventually may supervene, but are characterized by less moisture, by 
more brittleness, and by a pleuritic exudation. The alveoli may remain 
permanently contracted, and are often obliterated by sclerosis of the inter- 
stitial tissue of the lung, in which case an indurated, pigmented, depressed 
scar remains. 

In atelectasis from compression a single lobe or even the entire lung 
may be involved, and the greater the compression the denser the lung 
and the paler the color, since both air and blood are expelled. In 
extreme cases the compressed lung is in a state of carnijication. It then 
forms a flattened, cake-like mass situated at the upper and posterior por- 
tion of the chest, and of a tough, leather-like consistency, non-crepitant, 
and of a bluish-gray color intermingled with black specks, which are more 
or less numerous according to the pre-existing quantity of pigment. 

Symptoms. — Atelectasis produces deficient aeration of the blood, 
but the degree is rarely so extreme as to give rise to characteristic 
symptoms. These, however, sometimes occur in congenital atelectasis, 
and the breathing of the infant is then rapid and superficial, the heart 
is weak, the veins are distended, and the extremities are cold. There 
are drowsiness and muscular twitchings, and death is a frequent result. 
The dyspnoea and cyanosis present in the capillary bronchitis of chil- 
dren and adults are in part attributable to existing areas of atelectasis. 
Protracted atelectasis in the foetus may interfere with the closure of the 
ductus arteriosus and of the foramen ovale, and the permanent atelec- 
tasis of the adult may give rise to collateral emphysema of the lung and 
to hypertrophy of the right side of the heart, with the liability to eventual 
degeneration. On physical examination of the chest, foci of atelectasis 
may be overlooked or the signs of capillary bronchitis be observed. 
Extensive atelectasis when superficial gives rise to dulness on percus- 
sion, or to a harsh respiratory murmur and increased vocal fremitus, as 
in pneumonia. It is to be distinguished from the latter disease by t lie 
gradual onset, the limitation to the dependent portions of the lung, and 
the association with an obvious cause. 

47 



738 



DISEASES OF THE RESPIRATORY APPARATUS. 



The prognosis of atelectasis depends npon its cause, and, therefore, is 
grave, perhaps fatal, in foetal atelectasis, and is serious according to its 
extent in the atelectasis of capillary bronchitis. Permanent disablement 
of the lung may take place in atelectasis from compression. 

Treatment. — In many cases of atelectasis all that can be done is to 
treat the underlying condition and to meet symptoms as they arise. In 
the new-born, artificial insufflation of the lungs by breathing into the 
mouth may be tried : if the stomach rather than the lungs is inflated, 
the practitioner should desist from this method of treatment ; intubation 
and blowing directly into the lungs through a rubber tube would seem to 
be a rational procedure in these cases. In cases of low fever the patient 
should not be allowed to lie upon the back, and should from time to time 
take deep inspirations as a prophylactic measure. In most cases of serious 
atelectasis it is especially important to support the heart. 

EMPHYSEMA. 

Definition. — Total or partial enlargement of the lung, sometimes 
from the presence of air in the interstitial tissue, but usually from dilata- 
tion and fusion of the alveoli, resulting in a diminution of the respiratory 
and vascular surfaces, and producing dyspnoea and cyanosis from imper- 
fect aeration of the blood. 

Etiology. — Interstitial emphysema is to be distinguished from essen- 
tial emphysema both in causation and in results. In interstitial emphysema 
air is present in the interstitial tissue of the lung in consequence of 
rupture of the respiratory surface, which usually takes place suddenly 
from a violent expulsive effort when the glottis is closed, as in a severe 
paroxysm of whooping-cough or in violent vomiting. With the renewal 
of the increased intra-alveolar pressure more and more air is forced into 
the interstitial tissue. Interstitial emphysema may result also from the 
aspiration of air when the lung is lacerated by a broken rib or in cut- 
throat. Essential^ alveolar, or vesicular emphysema is caused by a weakness 
of the alveolar wall and an increase of intra-alveolar pressure. The 
weakness of the wall is especially attributable to deficient or degenerated 
elastic tissue. The deficiency of elastic issue is, perhaps, of congenital 
origin, since repeated instances of the occurrence of emphysema have 
been observed in certain families. Degeneration of the elastic fibres is 
likely to result either from inflammation of the lung or from prolonged 
intra-alveolar pressure, as in forced expiration, perhaps also from inten 
sified inspiration, as in the prolonged inhalation of rarefied air. Impor- 
tant in the causation of increased alveolar pressure are chronic and violent 
coughing, as in chronic bronchitis, frequent attacks of asthma, excessive 
strain of. the voice, but especially those occupations which demand per- 
sistent, prolonged expiration, as the use of wind instruments. Eniplry- 
sema occurs at all periods of life, but is most common in middle age, and 
its frequency increases with advancing years. 



DISEASES OF THE LUNGS. 



739 



Morbid Anatomy. — In interstitial emphysema large and small bub- 
bles of air are to be seen beneath the pleura and between the lobules, 
and follow the course of the interstitial tissue along the bronchi and 
blood-vessels towards the root of the lung. The inflation of the fibrous 
tissue may thence extend into the neck and appear beneath the skin as a 
subcutaneous emphysema, which may be continued over the entire body. 
If the overlying pleura is also ruptured, the air escapes from the inter- 
stitial tissue into the pleural cavity, and pneumothorax results. 

The changes occurring in alveolar emphysema are distributed through- 
out the lungs or are limited to certain portions, in which latter case the 
emphysema is called vicarious, collateral, or complementary, since it repre- 
sents the distention of a limited portion of a lung in consequence of the 
inability of air to enter neighboring parts. The emphysematous lung 
remains distended from loss of elasticity, is abnormally pale from the 
presence of fewer blood-vessels, and has a downy feel, which is often the 
most conspicuous characteristic of the emphysema of old age, senile em- 
physema. The alveoli as seen through the pleura appear unusually large, 
and trabeculated cavities may be present of the size of a hen's egg, due 
to the fusion of numerous dilated alveoli. The distention and fusion 
of the alveoli are most extreme where the lungs most readily yield, — 
namely, at the apices and along the anterior border. The wall between 
adjoining alveoli is early perforated and eventually absorbed, and in con- 
sequence a destruction of the pulmonary capillaries takes place corre- 
sponding to the extent of respiratory surface affected. The mucous 
membrane of the larger bronchi usually presents the characteristics of 
chronic bronchitis, and the smaller bronchi are often slightly dilated. 
The right side of the heart is hypertrophied and dilated, and evidences 
of chronic endarteritis are frequent in the pulmonary artery. In pro- 
tracted cases, when degeneration of the right ventricle follows hyper- 
trophy, there are nutmeg atrophy of the liver and cyanotic induration 
of the kidneys. 

Symptoms. — When emphysema has reached a sufficient degree to pro- 
duce discomfort it is manifested by short, wheezing respiration and by 
dyspnoea on slight exertion. If the emphysema occurs acutely, as in the 
interstitial variety, the dyspnoea is quickly followed by cyanosis. In 
chronic emphysema, however, cyanosis is a late manifestation, and is de- 
pendent on the progressing incompetency of the hypertrophied right ven- 
tricle. There are frequent cough from the associated bronchial catarrh, 
disturbance of digestion, emaciation, and eventual dropsy. The patient 
with pronounced alveolar emphysema has a barrel-shaped chest, except 
in senile emphysema, in which the chest expands but little on inspiration. 
The back is rounded, the supraclavicular fossae are distended by the pul- 
monary apices, the intercostal spaces are widened and protruded on ex- 
piration, and a wreath of dilated small veins is frequent in the region of 
the insertions of the diaphragm in the thoracic wall. There is increased 



740 



DISEASES OF THE RESPIRATORY APPARATUS. 



resonance on percussion, and the resonant area extends abnormally low, 
both laterally and in the back. Cardiac dnlness is largely replaced by 
the resonance of the superjacent lung, except in senile emphysema. The 
area of hepatic dulness also is diminished, and the anterior border of the 
liver often lies below the costal cartilages. On auscultation the respi- 
ratory murmur is feeble, and there is prolonged expiration. From the 
frequently associated bronchitis, moist and dry rales are common. On 
auscultation of the heart there is accentuation of the second pulmonic 
sound, and in the later stages of emphysema a systolic murmur due to 
relative insufficiency of the tricuspid valve is to be heard near the ensi- 
form cartilage. The urine eventually presents the characteristics to be 
found in chronic passive congestion of the kidneys. 

The diagnosis of essential emphysema is readily made from the 
physical characteristics of the patient, and the prognosis is unfavorable 
as to recovery, although the disease is not incompatible with prolonged 
life. If death does not result from intercurrent disease, it usually follows 
progressive weakening of the heart. 

Treatment. — The treatment of emphysema is chiefly that of the dis- 
ease which produces it, hence in a large proportion of cases it is the treat- 
ment of chronic bronchitis or of asthma. As the addition of the emphy- 
sema to the original disease makes a serious complication, all that is pos- 
sible should be done to avoid the recurring attacks of the original disease. 
Thus, the existence of emphysema in a case of chronic bronchitis makes 
it imperative, if possible, to change the residence to a suitable climate, 
and the musician may be obliged to give up the use of the wind instru- 
ment. As in very many cases of emphysema the right side of the heart 
is weak, the cardiac tonics play an important part in the treatment of the 
disease ; strychnine, acting as it does simultaneously on the circulation 
and the respiration, is an especially important remedy, and may be given 
for a great length of time continuously in slowly ascending amounts until 
massive doses (one-twelfth of a grain) are reached. It is especially 
important in these cases to treat the secondary disorders of function 
produced by the venous engorgement. Digestive disturbances must be 
carefully attended to. 

In Germany the mechanical treatment of Gerhardt is said to be much 
used in emphysema with marked benefit. It consists in having expira- 
tion mechanically assisted by compression of the thorax ; about ten 
minutes every day a muscular person places the hands flatly upon the 
sides at the bottom of the thorax of the patient and compresses actively 
at the end of expiration. The breathing of rarefied air by means of 
Waldenburg's portable cabinet is said also in many cases to give great 
relief. It is even asserted that an improvement in the physical signs of 
emphysema can sometimes be demonstrated as the result of systematic 
pneumatic treatment. 



DISEASES OF THE LUNGS. 



741 



ACUTE PNEUMONIA. LOBAR PNEUMONIA. FIBRINOUS PNEU- 
MONIA. CROUPOUS PNEUMONIA. 

Definition. — An acute infectious disease pursuing a more or less 
typical course, caused by the invasion of the lung by a variety of bacteria, 
chiefly the diplococcus pneumoniae, characterized anatomically by a fibri- 
nous inflammation of the lung and clinically by continued fever, by dys- 
pnoea, and by a variety of symptoms due in part to the absorption of 
toxins from the diseased organ. 

Etiology.— Pneumonia occurs in all parts of the world, but with 
various frequency. In Norway, according to Holmsen, from four per 
cent, to eleven per cent, of the entire population are infected, and Bary 
stated that from three per cent, to four per cent, of the patients in a 
number of hospitals in St. Petersburg had pneumonia. In those regions 
in which it is prevalent about seven per cent, of all deaths are due to 
this disease, — for example, eight per cent, in Massachusetts and seven per 
cent, in Louisiana. It occurs more often in winter and spring than at 
other seasons, and is found in men four times as often as in women. 
It is especially frequent in young adults, and the pneumonia of children 
under two years of age, according to Southworth, is of a lobar character 
in one-third of the cases. The weak and debilitated, whether from lack 
of food, overwork, bad hygienic surroundings, disease, or old age, and 
those exposed to cold and wet, are oftenest attacked. It is common in 
malarial regions. Although gout is supposed by many English writers 
to be of etiological importance, the experience at St. Thomas's Hospital 
opposes this view. Injuries, such as falls and blows, are occasionally 
followed by pneumonia, the contusion apparently diminishing the power 
of the individual to resist the activity of the more immediate cause. 

The infectious nature of pneumonia was inferred long before the dis- 
covery of the micro-organisms which have been found to be of etiologi- 
cal importance by the frequent typical course, by the independence of the 
general symptoms and pulmonary lesions, by the occurrence of epidemics 
and endemics, and by its outbreak in persons soon after their exposure 
to other cases. The observations of Eberth, Koch, Friedlander, Ley den, 
Gunther, Fraenkel, and others have demonstrated that bacteria are 
always present in the exudation of pneumonia, and that in about eighty 
per cent, of all cases a definite variety, the diplococcus pneumonias, is 
to be found. This organism has been proved to be identical with one 
which had been isolated in the sputum by Sternberg and Pasteur. It has 
been found not only in the inflamed lung, but also in the blood of patients 
with pneumonia. It has been observed in the numerous complications 
of pneumonia, as pleurisy, pericarditis, endocarditis, meningitis, peritoni- 
tis, and arthritis, and in various suppurative inflammations occurring in 
this disease and independently of it. Many of these localized inflamma- 
tions have been produced experimentally by the introduction into the 



742 



DISEASES OF THE RESPIRATORY APPARATUS. 



tissues of this diplococcus. Pneumonia, therefore, is to be regarded 
merely as one of the results, although the most frequent, of the invasion 
of the individual by this organism, the inflammation of the lung being 
the local manifestation of its entrance into the body. Other bacteria 
have been found in pneumonia, — namely, Friedlander' s bacillus, the in- 
fluenza bacillus, the streptococcus pyogenes, the staphylococcus aureus, 
and the typhoid bacillus in the pneumonia of typhoid fever. The pres- 
ence of any of these as the especial bacteriological characteristic of the 
disease is exceptional as compared with that of the diplococcus pneu- 
moniae. 

This diplococcus, also called pneumococcus and micrococcus lanceo- 
latus, usually appears in pairs, the individual cocci being rather ovoid 
than round, and their outer ends are somewhat pointed. The organism 
is stained readily by any of the aniline dyes and by Gram's stain, by 
means of which it is to be distinguished from the pneumobacillus of 
Friedlander. An important diagnostic feature is the presence of a cap- 
sule, which can be determined by appropriate staining. 

Morbid Anatomy. — The characteristic appearances are due to the 
accumulation in the alveoli and smaller bronchi, more rarely in the large 
tubes, of fibrin and cells, which in favorable cases undergo absorption. 
The progress is divided arbitrarily into three stages, namely, congestion 
or engorgement, hepatization, and resolution, although each of the three 
stages may be present simultaneously in the same lung. Ordinarily an 
entire lobe is diseased : hence the term lobar pneumonia. Sometimes two 
lobes are inflamed, and in about one-sixth of the cases both lungs are 
involved. In three-fourths of the cases the lower lobe is affected, — 
oftenest of the right lung, — and in one-half of the cases it is the only 
lobe diseased. The upper lobe is inflamed in two-fifths of the cases, 
being alone diseased in about one-fifth of them. 

In the stage of engorgement, which usually lasts about twenty-four 
hours, although it may be prolonged for several days, the affected portion 
of the lung is distended, dark red, heavy, and dense. On section there 
escapes a somewhat viscid, bloody fluid, the result of combined con- 
gestion and oedema, and containing many small air-bubbles. Micro- 
scopical examination of the lung at this stage shows that the alveoli are 
filled with an albuminous fluid in which are desquamated swollen epithe- 
lium, red blood-corpuscles, and leukocytes. The capillaries are injected 
and tortuous. 

The second stage usually begins on the second day of the disease, and 
is called hepatization, from the fancied resemblance of the diseased lung to 
the liver. The alveoli contain fibrin in addition to cells. The distended 
lung is increased in weight perhaps threefold. The heavy portions sink in 
water, and are non- crepitant and friable. Transverse depressions are to 
be seen upon the surface of the lung, caused by the pressure of the ribs, 
and a fibrinous membrane covers the pleura, which consequently is dull 



DISEASES OF THE LUNGS. 



743 



and opaque. On section the surface is either red or gray, according to 
the quantity of blood present, which is greater in the early and less in 
the late stage of the hepatization. The cut surface appears granular from 
the projection of the clotted fibrin in the alveoli. Ordinarily the granules 
are minute, but in an emphysematous lung they are large. The exuda- 
tion may be dark red in case hemorrhage is a complication, and the lung 
is dotted with black spots when there is excessive carbonaceous pigmen- 
tation. The interstitial tissue is frequently swollen and opaque from the 
presence of the exudation in the course of the lymphatics. In old people 
and in those enfeebled by chronic disease the quantity of fibrin in the 
exudation is not as abundant, consequently the lung is less dense and 
more moist. 

In resolution the lung is less solid and resistant, and the cut surface 
exudes on pressure an opaque puriform fluid, and appears smooth in- 
stead of granular. These changes are due to the fatty degeneration and 
softening of the exudation. The lung-tissue is easily crushed, the puri- 
form fluid fills the gap, and thus the presence of an abscess is frequently 
simulated. 

Although hepatization is followed normally by resolution, if for any 
reason the blood-supply of the inflamed portion of the lung is inter- 
fered with gangrene readily occurs from the passage of putrefactive bac- 
teria in the bronchi into the diseased part. The gangrenous portions 
may be separated from the rest by an inflammatory line of demarcation, 
and an abscess result in which the necrotic tissue lies loose. In rare 
instances the hepatized lung does not undergo resolution, but forms a 
reddish-gray, homogeneous, airless mass. (See Chronic Pneumonia.) 

The associated lesions are due to absorption of the bacterial toxin 
into other organs of the body, or depend upon the direct entrance of the 
bacteria into the circulation and their development in some other organ. 
The lymphatics at the bifurcation of the trachea are large, soft, and 
injected ; the spleen also is large and soft and of a reddish-gray color from 
hyperplasia of the pulp. Granular degeneration of the heart, liver, and 
kidneys is usually present. Pericarditis is common when the left lung 
is attacked, endocarditis, either simple or ulcerative, may be present, and 
diplococci are usually to be demonstrated in the exudation or in the 
diseased valves. A rare complication, and then associated with endo- 
carditis, is inflammation of the pia mater, in which case the diplococcus 
of pneumonia is found in the meningeal exudation. 

Symptoms. — For two or three days before the onset of pneumonia 
there is in a certain number of cases a nasal or pharyngeal catarrh or 
slight general discomfort. The first symptom of the affection of the lung 
is a chill, generally sudden, and mild or severe irrespective of the course 
which the disease is to take. The chill is soon followed by fever and 
thoracic pain unless the inflamed portion of the lung is deep-seated. 
The pain is usually referred to the nipple of the affected side, but may 



744 



DISEASES OF THE RESPIRATORY APPARATUS. 



be located in the axillary region or in the back. Dyspnoea then takes 
place, is perhaps synchronous with the pain, and is dne probably to the 
engorgement of the lung with frothy, bloody fluid, the presence of which 
is made evident by numerous coarse and fine, moist and dry rales. As 
the solidification of the lung progresses, the pain lessens, but the fever 
and dyspnoea persist. There is but little appetite, thirst is not extreme, 
constipation is the rule, and the occurrence of diarrhoea, especially late 
in the disease, is indicative of the serious nature of the attack. The 
face is flushed and the expression anxious ; the respiration is superficial, 
labored, and often interrupted by a distressing short cough. The expec- 
toration is scanty, tough, and viscid, and of a rusty color. The patient 
is restless, perhaps delirious, and suffers from headache, backache, and 
weakness. The pulse throughout is full and strong, and in the beginning 
there is marked pulsation of the carotids. 

Eesolution takes place commonly between the fifth and the eighth 
day, rarely earlier, often later. The temperature then falls several 
degrees, either suddenly, by crisis, or gradually, by lysis; the dyspnoea 
diminishes, the cough is less distressing, the expectoration is more abun- 
dant, and the general symptoms improve, although the signs of solidifica- 
tion continue, as a rule, for a number of days afterwards. 

The temperature rises rapidly after the chill, and within twenty-four 
hours is generally 104° or 105° F. It usually remains thus elevated, with 
slight morning remissions and evening exacerbations, until the critical 
fall, which oftenest occurs on the seventh or eighth day, but may be 
delayed for several days. At times a pseudo- crisis appears on or about 
the third or fourth day, but the temperature rarely reaches the normal 
and quickly returns to the maximum. In a certain number of cases the 
temperature falls gradually, attaining the normal point in the course of 
a few days instead of in a few hours. Persistence of high temperature 
beyond the time when the critical fall is to be expected, or the appear- 
ance of wide variations in the daily range of temperature, should arouse 
suspicion of a complicating gangrene or suppuration. 

The frequency of respiration in most cases is between thirty and forty 
per minute, the number of respirations being higher in children, in weak 
and in nervous patients, and in cases where large portions of the lung 
are involved. 

The pulse is usually between 110 and 120, not increasing in proportion 
to the frequency of respiration. The rate may be considerably faster 
than this in children and nervous persons, and be below 100 in elderly 
people. A fall of forty or fifty beats at the time of the crisis is not 
unusual. In the earlier days of the pneumonia the pulse is full and 
bounding, but as resolution approaches it is soft, compressible, and per- 
haps dicrotic. 

The cerebral symptoms are especially marked in children and in 
alcoholic persons. In children convulsions may be among the incipient 



DISEASES OF THE LUNGS. 



745 



symptoms of pneumonia, delirium is early among abusers of alcohol, and 
delirium tremens is likely to occur late in the disease. Mild delirium is 
frequent among elderly people and persons of a nervous temperament. 

Physical Examination. — The patient is found lying on the back or 
the affected side according as the pain makes it necessary to limit the 
movements of the chest. The body is bent forward, the head is raised, 
and the nostrils are expanded with each inspiration. There is a bright- 
red flush on each cheek, while the lips and nose are dusky and the rest 
of the skin is pale. Rarely there is a slight degree of jaundice. As a 
rule, there is profuse sweating, frequently accompanied with sudamina ; 
herpes of the lips or nose is present in about one-third of the cases. 

The examination of the chest shows a limitation of movement on the 
affected side. Palpation gives an increase in the vocal fremitus unless 
there is also pleuritic effusion. In the early stages friction may often 
be felt. During the stage of congestion the resonance on percussion is 
likely to be increased, perhaps tympanitic, but with the development of 
hepatization is replaced by dulness, almost flatness, oftenest first recog- 
nized in the subscapular region and near the posterior axillary line. If 
aerated lung-tissue overlies the hepatized portion of the lung there is 
resonance on percussion. As resolution advances, the dulness gradually 
disappears. 

On auscultation in the stage of congestion fine crepitant, so-called 
subcrepitant, rales are to be heard, caused by a viscid exudation in the 
alveoli, and frequently accompanied by coarse moist rales produced in 
the bronchi. As hepatization progresses, the rales disappear and the 
breathing becomes tubular, or ceases in case the larger bronchi are ob- 
structed. When resolution takes place there is a return of the fine 
moist rales, — crepitus redux, — and coarser rales soon follow. In central 
pneumonia the transmission of the rales is interfered with by the over- 
lying aerated lung. On auscultation of the heart the , second pulmonic 
sound is accentuated, and on palpation and percussion in the region of 
the spleen and liver these organs are found frequently enlarged. 

The sputum of pneumonia is usually characteristic of the disease. 
It is sometimes scanty, and may be wholly absent. At the outset it is 
streaked with blood and is so viscid as to adhere to the side of the 
inverted cup. During hepatization it is more abundant, gelatinous, of a 
reddish-yellow color from the presence of decomposed blood-pigment, 
hence called rusty. In severe cases, when there is abundant hemorrhage, 
the sputa are liquid and of a dark-brown color resembling prune-juice. 
During resolution they are thick and yellow, muco-purulent in character. 
In certain cases the sputum is green,— according to Yon Jaksch, from 
the transformation of haemoglobin into bilirubin. Fibrinous casts of the 
bronchioles and alveoli are often present, and may be recognized in the 
sputum diluted with water and spread upon a glass plate. Diplococci 
of pneumonia are to be found often in the sputum, but their presence is 



746 



DISEASES OF THE RESPIRATORY APPARATUS. 



not necessarily of diagnostic value, since they may be seen when there 
is no pneumonia. 

Examination of the blood shows almost invariably a leukocytosis, 
which, as a rule, becomes greater as the disease advances. According to 
Ewing, it is usually between twenty thousand and thirty thousand, and, 
in general, the higher the leukocytosis the more severe the disease ; but, 
exceptionally, in very grave cases there may be little or no increase in 
the number of leucocytes. In the absence of all physical signs per- 
mitting the localization of a suspected pneumonia, the occurrence of a 
marked leukocytosis is in favor of such a condition with a central seat. 
Sudden increase of an existing leukocytosis occurs when the disease 
extends to a hitherto unaffected portion of the lung. The number of 
leukocytes rapidly returns to the normal after the crisis is reached. 

The urine is scanty, high-colored, and concentrated. The chlorides 
become very much diminished early in the attack, but return after the 
crisis. Albumin is found in the urine in small amounts in about one- 
third of the cases, and is associated with the presence of hyaline casts. 
Both albumin and casts usually disappear in the course of a few days 
after convalescence. According to Von Jaksch, the appearance of pep- 
tone in the urine is indicative of the beginning of resolution. 

Varieties. — All cases of pneumonia do not run the same typical 
course, and the genuine, frank, sthenic pneumonia has been long dis- 
tinguished from the atypical, asthenic, or typhoid pneumonia. It seems 
not unlikely that the variation in the course may be due in part to differ- 
ences in etiology, the more common typical variety being caused by 
the diplococcus of pneumonia, while those pursuing an atypical course, 
or occurring as complications of other diseases, as typhoid fever, malaria, 
or nephritis, may result from the bacilli of typhoid fever or of influenza, 
or from staphylococci or streptococci, either alone or in combination with 
the diplococcus. , The typical course of genuine pneumonia also varies 
frequently in consequence of the age and the general condition of the 
patient, and the presence of complicating diseases. In children, in 
whom, as already stated, lobar pneumonia is much more common than 
has been generally supposed, there are rarely typical consolidation and 
physical signs. The initial chill is often absent, perhaps replaced by a 
convulsion, and the mortality is low. In elderly people, on the other 
hand, the chill and characteristic signs of hepatization may be absent, 
but the disease is very fatal. In alcoholic subjects the symptoms and 
signs referable to the chest may be so inconspicuous that the pneumonia 
is overlooked, delirium being the striking feature. In typhoid fever the 
course of the pneumonia is greatly modified by the toxic condition due to 
the typhoid bacillus. The term typhoid pneumonia indicates merely the 
association of low, muttering delirium, extreme prostration, a dusky, 
perhaps yellow skin, and diarrhoea, conditions which occur in varieties 
of pneumonia independent of typhoid fever and of the typhoid bacillus. 



DISEASES OF THE LUNGS. 



747 



In malarial regions it is observed that consolidation of the lungs appears 
insidiously, the typical symptoms being absent, resolution is slow, ter- 
mination in abscess is frequent, and the mortality is high. In rare 
instances the symptoms and signs of pneumonia disappear at the end of 
two days, and the patient is said to have had an ephemeral pneumonia, or 
an attack of congestion of the lungs. In other cases resolution takes 
place in the course of twenty-four hours, and recovery and convales- 
cence begin from the third or fourth day. To this condition the term 
abortive pneumonia is applied. Apical and central pneumonias are dis- 
criminated. In the former the infiltration begins in the upper lobe, and 
frequently pursues a severe course, associated with severe cerebral symp- 
toms, — hence cerebral pneumonia. In central pneumonia, although the 
symptoms indicate an inflammation of the lung, the physical signs, with 
the exception of localized, apparently deep-seated, bronchophony and 
bronchial breathing, are absent. In wandering pneumonia, which some- 
times, though not necessarily, is preceded by facial erysipelas, one portion 
of the lung after another is continuously involved. The discovery of 
streptococci in the exudation in certain of these cases suggests that the 
peculiar course may be due to this variety of bacterial infection. 

Complications. — The complications are due either to the direct ex- 
tension of the inflammatory process to neighboring organs or surfaces, or 
to the lodgement and development of the diplococci in distant organs. 
Bronchitis is one of the most frequent accompaniments of pneumonia, and 
its presence is indicated by coarse moist rales. The presence of pleurisy 
is so constant that the term pleuro -pneumonia is often used as a synonyme 
of pneumonia. In pneumonia of the central portions of the lung, how- 
ever, the pleura is free from alteration. The variety of pleurisy oftenest 
observed is the dry or fibrinous pleurisy, the fibrinous exudation forming 
a thick or thin layer on the surface. There is usually no considerable 
quantity of serous fluid in the pleural cavity, but in certain instances pus 
is present, and the case then runs the course of an empyema. The peri- 
cardium is often inflamed, especially in pneumonia of the left lung, and, 
although the pericardial exudation is generally fibrinous and sometimes 
very scanty, in rare instances there may be large quantities of fluid, which 
may be of a sero-purulent character. Endocarditis, especially of the 
aortic and mitral valves, is a frequent complication of pneumonia, and 
the characteristic diplococci have been found repeatedly in the vegeta- 
tions. According to Osier, nearly twenty-five per cent, of the cases of 
malignant endocarditis occur in this disease. Arterial embolism may 
thus arise as a complication, and is perhaps explanatory of the reported 
occurrence of symmetrical gangrene in the sequence of pneumonia. As 
has been stated previously, meningitis with pneumococci in the exudation 
at times occurs independently of pneumonia, and inflammation of the 
lung is a frequent condition in cerebro spinal meningitis. Peripheral 
neuritis has been observed as a complication of pneumonia, as have also 



748 



DISEASES OF THE RESPIRATORY APPARATUS. 



parotitis, arthritis, and orchitis, and the diplococci of pneumonia have 
been found in the accompanying exudation. Nosebleed and intestinal 
hemorrhage at times occur late in the disease, and acute nephritis, with 
hematuria as a complication, occasionally is present. There may be 
profuse flowing when miscarriage or premature labor occurs. 

Diagnosis. — The onset of an attack of pneumonia is usually so typical, 
and the development of the physical signs so marked, that but little diffi- 
culty is encountered in the diagnosis of most cases. When, however, the 
localization is central, the physical signs are often so obscured by the over- 
lying aerated lung that the diagnosis is to be inferred almost wholly from 
the symptoms and from the exclusion of other causes of thoracic disease. 
If the patient is seen first at a late stage, the diseased lung may be covered 
with a serous or a purulent exudation and the signs of consolidation be 
concealed until the removal of the pleuritic exudation permits them to 
be transmitted to the ear. Attention has been called already to the 
diagnostic importance of examination of the blood in such cases. The 
progress of the pneumonia may be so retarded that consolidation is de- 
layed for several days, especially in children, in old people, and in those 
suffering from chronic disease. The sudden onset of cerebral symptoms 
in children and of delirium tremens in persons addicted to alcohol, when 
associated with fever and rapid respiration, necessitates always a physical 
examination of the chest. 

Acute oedema of the lungs closely simulates the early stage of pneu- 
monia. There are dyspnoea, frothy, bloody sputum, and fine moist rales. 
In oedema, however, fever is absent, and there is evidence usually of val- 
vular endocarditis. The rales are present throughout the chest, and not 
limited to a lobe of the lung as in pneumonia. The solidification of the 
lung in acute pulmonary tuberculosis is occasionally mistaken for acute 
pneumonia, and the bacilli of tuberculosis may be absent from the sputum 
until pulmonary hemorrhage or softening arises. The febrile course of 
acute tuberculosis is less typical than that of pneumonia, resolution fails 
to take place at the usual time, and the characteristic bacilli appear 
eventually in the sputum. Acute pleurisy is often confounded with pneu- 
monia, for its onset may be equally sudden, and announced by a chill, 
thoracic pain, and dyspnoea. In both diseases dulness on percussion, 
bronchial breathing, bronchophony, and crepitation occur. In pleurisy 
there is usually displacement of the heart or of the liver, and tactile and 
vocal fremitus are faint or absent. The abnormal respiratory sounds are 
confined for the most part to the upper part of the dull area, while in 
pneumonia they are more marked in the lower portion of the region of 
dulness. In case of continued doubt the chest should be punctured with 
the exploratory needle. 

Prognosis. — Although it has been estimated that between one- sixth 
and one-fourth of all cases of pneumonia prove fatal, the statistics aid but 
little in the prognosis of the individual case, owing to the importance of 



DISEASES OF THE LUNGS. 



749 



the peculiarities of the individual, especially as determined by age, 
habits, and complicating diseases. Children generally recover from 
fibrinous pneumonia. In persons above sixty the mortality is high. In 
alcoholic subjects the mortality may be even fifty per cent. The prog- 
nosis of pneumonia is serious when it is a complication of emphysema, 
heart disease, nephritis, diabetes, or advanced pregnancy. The more 
extensive the area of lung involved the graver the prognosis, it being 
especially severe in double pneumonia. The mortality in pneumonia of 
the upper lobe, so often associated with cerebral disease, is generally con- 
sidered higher than in pneumonia of the base, although numerous excep- 
tions exist. In asthenic or in bilious pneumonia with typhoidal symptoms 
the prognosis is far less favorable than in typical fibrinous pneumonia. 

Death takes place usually during the stage of red hepatization, and 
shortly before the expected crisis, although now and then it occurs during 
the incipient stage of engorgement, or soon after crisis has taken place. 
It is generally the result of cardiac incompetency and asphyxia, due in 
part to the effect upon the nervous system of the toxin of the diplococ- 
cus of pneumonia, and in part to the solidification of the lung. The 
ominous symptoms are a persistent increase in the frequency of the pulse 
and respiration, tracheal rales, prune-juice sputum, stertorous breathing, 
cyanosis, and muscular tremor. The grave prognostic importance of 
extreme, slight, or absent leukocytosis has been previously mentioned. 

Treatment. — In the treatment of pneumonia it is essential to recog- 
nize that, though the disease may be a unit from the pathological point 
of view, therapeutically it comprises essentially diverse diseases. A 
pneumonia whose physical signs cannot be made out in the beginning, 
but gradually creep up towards the chest-wall, — a pneumonia whose ex- 
pectoration is in the beginning prune-juice, whose crepitant rale is never 
typical, whose physical signs are obscure until complete consolidation 
gives percussion dulness, — or a pneumonia occurring in the alcoholic, in 
the old, in the victim of renal disease, in the broken-down debauchee, in 
the worn-out city merchant or professional man, — is in its management 
essentially distinct from a pneumonia the result of exposure of a strong, 
healthy countryman to a Western blizzard or other cold. Hence the folly 
of statistical inquiries into the mortality of different methods of treat- 
ment of pneumonia, — statistics in which all the forms are lumped to- 
gether as if they were one disease. In one form of pneumonia sedative 
treatment may kill the patient ; in another form sedative treatment at 
the beginning of the attack may be necessary for the saving of the patient. 
When in the first twenty-four hours of a pneumonia there is violent con- 
stitutional reaction, with flushed face, rapid and noisy breathing, bloody 
sputa, intense headache and drowsiness, a hard bounding or a tense corded 
pulse, venesection may markedly lessen all the symptoms, and if com- 
bined with dry cupping over the whole chest may, we believe, lessen the 
amount of engorgement of the lung and the final area of consolidation. 



750 



DISEASES OF THE RESPIRATORY APPARATUS. 



During the bleeding the patient should sit up, and the blood should be 
taken rapidly from a large orifice until some impression is made upon the 
pulse, or until twenty-five or even thirty ounces have been abstracted. 

Nevertheless, if it were possible in any way to obtain the immediate 
effects of the venesection without the after- exhaustion, such procedure 
would be preferable to blood-letting. Veratrum viride in full dose, 
by reducing the force of the heart, diminishes the vis a tergo which 
drives the blood to the lungs, and at the same time dilates the ab- 
dominal blood-vessels and so invites the blood into them. As these 
abdominal blood-vessels can, when fully relaxed, contain all the blood of 
the body, the action of veratrum viride is decisive. Its influence, how- 
ever, lasts but a few hours, so that its withdrawal is rapidly followed by 
return of the circulation to the norm without exhaustion. The veratrum 
viride treatment of robust cases of pneumonia bleeds a man into his own 
blood-vessels, but allows the return of this blood to the circulation when 
the stage of consolidation is reached without persistent depression to 
the heart or the vessels themselves. In order to obtain these effects the 
veratrum viride should be given freely (three to five minims of the 
tincture, two to three minims of the fluid extract) every forty minutes 
until nausea is produced. Vomiting should be the signal for its imme- 
diate withdrawal. The veratrum viride treatment of pneumonia differs 
from the older method of Easori, in which enormous doses of antimony 
were given, in producing only temporary depression : the antimony in 
the large doses used caused not only excessive discharge from the stomach, 
but also violent serous purging, with its consequent exhaustion. 

In the great majority of cases of pneumonia as seen in our large cities, 
active depressing treatment even in the beginning is not useful ; and in 
all cases after consolidation has set in, the efforts of the physician must 
be directed to maintaining the forces of the patient and mitigating the 
symptoms. 

The usual causes of death in pneumonia are general exhaustion, failure 
of the right heart, and failure of the respiratory forces. The causes of 
exhaustion are the high temperature, the loss of material from the blood 
into the diseased lung, and the blood-poisoning from the secondary 
products in the inflamed tissue. Over two of these sources of exhaustion 
we have little or no control ; the question how far we should attempt to 
reduce temperature is vital, but is in practice answered very differently 
by different practitioners. The fever in pneumonia lasts but a few days i 
hence a temperature of 103° F. , which in a long-continuing pyrexia like 
that of typhoid fever is serious, is a matter of little importance in a 
pneumonia, and in most cases may safely be disregarded. If, however, 
the temperature rise to 104° F. or above, it is important that it be re- 
duced, and we believe that its reduction by the external use of cold is 
much safer than by large doses of antipyretic drugs. 

These drugs in large dose are sedatives to the circulation, but the 



DISEASES OF THE LUNGS. 



751 



small dose of antipyrin has no such effect, so that in pneumonia this drug 
and its allies may be used in small dose to moderate nervousness, to 
lessen the bodily temperature when it is above the norm, and to prolong 
the effect of the cool bath in severe fever. ~No more than five grains 
of antipyrin should be given at once, nor more than ten grains in the 
twenty-four hours. Among antipyretic remedies may be mentioned qui- 
nine. In order to obtain from it any effect upon the temperature it is 
necessary to give it in doses of thirty grains a day, which are so disturb- 
ing to the patient, and, after all, so ineffective, that their administration 
does not seem to us justifiable. If employed at all, quinine should be 
used rather as a stimulant, not over fifteen grains a day. 

We believe that in cases of pneumonia much injury is frequently done 
by the retention of heat by poultices and other applications to the lung. 
(See Acute Bronchitis. ) Cold wet compresses, or even the ice-bag, may 
be often applied with great advantage over the affected lung ; in many 
cases tepid baths (85° to 90° F.) are of great service if properly used. 
No exertion on the part of the patient should be allowed : he should be 
lifted into the bath, or the cot-bath may be employed. (See Typhoid 
Fever. ) The bath is usually followed by sleep, with lowered respiration 
and a sense of refreshment. In very weak people and in children the 
temperature of the bath may be a little above 90° F. When the fever is 
very high the bath temperature may be as low as 80° F. Usually it is 
better to cool the water while the patient is in the bath than to immerse 
him directly in cold water. 

To prevent exhaustion by maintaining the forces of the patient is 
the great object of the nursing in a case of pneumonia. Absolute con- 
finement to bed is to be enforced from the beginning of the attack, the 
patient, however, being allowed to sit up if more comfortable in that 
position. The sick-room should be kept as quiet as possible ; the feeding 
should be at short intervals (two to three hours) ; the food should be 
simple, nutritious, and digestible, — milk, milk products, raw eggs, light 
meats, such as birds or sweetbreads ; if the digestion be very good, a 
moderate amount of farinaceous food may be allowed, but in most cases 
it has a tendency to produce flatulence and is objectionable. Cold drinks 
should be allowed as freely as the stomach will bear. 

In the beginning of sthenic pneumonia alcohol is injurious ; in the 
advanced stages it may be used in small quantities with the food to aid 
digestion, or, if there are evidences of exhaustion or of cardiac failure, 
may be given freely. At this stage the disease from a therapeutic point 
of view is allied to an infectious fever, much of the constitutional dis- 
turbance being due to the absorption of poisonous products from the 
affected area : hence stimulants should be given as they would be em- 
ployed in a similar condition occurring in a low fever. The alcohol is 
of value as a cardiac stimulant, but cannot take the place of digitalis, 
strychnine, and cocaine. 



752 



DISEASES OF THE RESPIRATORY APPARATUS. 



In the advanced stages of a severe pneumonia digitalis in doses of 
from five to fifteen minims of the tincture at intervals of from four to six 
hours often acts most happily as a heart stimulant and tonic, and seldom, 
if ever, interferes with digestion. Its effect upon the pulse should be the 
guide to its administration : whenever the pulse-rate falls to eighty-five, 
or even to ninety, the drug should be in part or altogether withdrawn, 
to be resumed when the effects wear off. 

As high temperature makes the heart insensible to digitalis, large 
doses are often necessary, and some care should be exercised at the time 
of the crisis lest the sudden fall of temperature bring about an over- 
action of the drug. 

Nitroglycerin and amyl nitrite have been strongly recommended by 
some practitioners as stimulants to the circulation in pneumonia. It 
should be remembered, however, that in any dose sufficient to produce 
perceptible effect these drugs always lower the arterial pressure by de- 
pressing directly the muscle-fibres in the blood-vessel walls, and that, 
although their first action upon the heart is that of a stimulant, the 
slightest overdose converts such action into that of a powerful depressant. 
Further, their effect lasts but a few moments. It is evident, therefore, 
that great caution is necessary in their use, and that they should not be 
employed when vaso-motor weakness is an already existing danger. In 
sudden cardiac failure they may at times, given in small doses, be of 
temporary value. 

Ammonium carbonate is very largely used, in the adynamic form of 
pneumonia especially, partly as a stimulant and partly on account of its 
alleged expectorant properties. There is no reason for believing that it 
has any direct influence upon the consolidated lung, and its power as a 
stimulant is certainly inferior. We have seen many hundreds of doses 
of it given in the disease, and have never been able to detect any effect 
upon the pulse or the respiratory rate. On the other hand, its free use 
readily endangers digestion. If given at all it should be in small doses 
(three grains in emulsion) at intervals of half an hour to an hour. Spirit 
of ammonia is preferable when the heart gives out suddenly or when an 
immediate effect is desired. It is, however, also of inferior value. 

Very important drugs in the treatment of pneumonia are the four 
alkaloids strychnine, cocaine, atropine, and caffeine, which act as stimu- 
lants both to the circulation and to the respiration. As a cardiac stimu- 
lant and tonic strychnine is inferior only to digitalis, and should always 
be used when there is exhaustion in pneumonia. Cocaine resembles 
strychnine in its cardiac action ; atropine as a heart stimulant is de- 
cidedly inferior, but exceeds both strychnine and cocaine in its influ- 
ence upon the vaso-motor centres, and is, therefore, especially applicable 
to those cases in which collapse occurs or is threatened at a time of 
crisis, at which period its power of checking excessive sweating often 
gives it further advantage. Of these alkaloids atropine is probably the 



DISEASES OF THE LUNGS. 



753 



most active in increasing respiratory movements in the normal man, but 
it has less power in asserting itself in the face of opposition than has 
either strychnine or cocaine, and is therefore practically less available. 
Strychnine seems to be more active and efficient than cocaine, and does 
not, as does cocaine, produce cerebral excitement. Caffeine cannot be 
looked upon as a powerful respiratory stimulant, but affects decidedly the 
cerebral cortex, and therefore, if employed at all, must be used in small 
dose as an adjuvant, or in special cases when it is desired to overcome 
stupor. 

Of all these remedies strychnine is the most generally available, but in 
severe cases the best results are to be obtained by the use of both strych- 
nine and cocaine. The strychnine and cocaine should be given alter- 
nately, in a bad case, every four hours, so that every two hours one of 
the remedies will be taken j ordinarily they may be exhibited by the 
mouth, but when the symptoms are alarming they should be admin- 
istered hypodermically. Each of them is a stimulant to the heart, and 
also to the vaso-motor system, so that they do more than simply aid in 
the maintenance of the respiratory forces. The dose should be increased 
according to the needs of the case, commencing with one-twenty-fourth 
grain of strychnine and one- sixth grain of cocaine, slowly increased to 
one-fourteenth grain of strychnine and one-half grain of cocaine. We 
have seen life apparently saved by even larger doses than these ; but 
when such doses are employed it is essential to have a judicious trained 
nurse under orders to reduce or suspend the drug should any evidence 
of overaction appear. When large doses are given at shorter intervals 
it should always be hypodermically, so as to insure their immediate 
absorption. 

The special indication for the free use of these respiratory stimulants 
is cyanosis, with hurried breathing and other evidences of respiratory 
distress. Under such circumstances the inhalation of oxygen gas some- 
times affords temporary relief. Its influence is very fugacious, and its 
inhalation often more or less irksome to the patient, so that its use should 
be restricted to times when the respiratory symptoms are very threaten- 
ing. Some authorities recommend the use of a mixture of oxygen and 
nitrous oxide. Nitrous oxide, however, is inert, is not decomposed in 
the system, and does not yield oxygen. It acts, therefore, only as a 
diluent, and if the oxygen needed diluting it would be better and cheaper 
to employ ordinary air for the purpose. It is hardly necessary to say 
that the preference should be given to pure oxygen. 

In advanced pneumonia, when cyanosis is very great and is accom- 
panied with distention of the right heart and with rapid respiration and 
great collateral engorgement of the lung, free venesection is recommended 
by some authorities. Momentary relief is certainly often obtained. The 
explanation of this is that the reduction in the amount of blood lessens 
the congestion of the lung and the work of the failing heart. It is very 

48 



754 



DISEASES OF THE RESPIRATORY APPARATUS. 



doubtful, however, whether the ultimate result is good. Osier states 
that of twelve cases which he bled uuder such circumstances eleven died, 
— a result which does not seem equal to that which could have been 
obtained by the free hypodermic use of digitalis, strychnine, and other 
cardiac stimulants. 

In many cases of pneumonia there is much pain in the chest, with 
general distress, which are greatly relieved by minute doses of opium 
in the form of Dover's powder or morphine. Whilst no hesitation 
should be felt in using opiates in small quantities, care should be exer- 
cised not to carry their administration so far as to interfere with an 
already embarrassed respiration. Hypnotics should be administered 
without hesitation when there is insomnia ; chloral is the most effec- 
tive, but should never be given when the heart is oppressed j sul phonal 
is probably the least disturbing, but is uncertain ; trional appears to 
be between the two in its action. Opiates sometimes act better than 
do any of the modern hypnotics. The combination of chloral (ten grains) 
with morphine (one-eighth of a grain) is sometimes excellent in its effect. 

When in a case of pneumonia the stage of consolidation is reached, 
the question whether it is possible in any way to hasten the softening 
and removal of the exudate is of great importance. The ordinary expec- 
torants are of no value. Even large doses of the alkaline expectorants 
(such as potassium citrate) do not sensibly increase the fluidity of the 
sputa. Pilocarpine, as suggested by Eiess, has some clinical reports in 
its favor, but we have never used it. 

The difficulty of determining in any individual case how far a drug 
which has been administered hastens resolution is very great ; we are, 
however, inclined to believe that mercury and the iodides have some 
power. The infective nature of the pneumonic process on theoretic 
grounds led to the practical abandonment of mercury, but we know now 
that mercury is a valuable drug in the treatment of serious infectious 
disease, — witness diphtheria : hence theoretically there is no objection to 
its use in pneumonia, whilst its proved power in hastening the breaking 
down of exudations seems to indicate its employment. Certainly, how- 
ever, if either mercury or the iodides be given, the doses should be so 
small that they can have no influence in deranging digestion or in in- 
creasing the general weakness. 

There are often in cases of pneumonia troublesome symptoms which 
must be met : headache is to be relieved by cold applications to the 
head, — sometimes by caffeine, or even by antipyrin, used cautiously ; 
if need be, hypodermic injections of morphine and atropine may be 
given. Such injections, also, are sometimes of advantage in relieving 
chest-pains. So far as the cough is concerned, the principles discussed 
in the article on Acute Bronchitis are applicable. Local applications 
to the chest are often useful in pneumonia. When venesection is not 
practised, or a little later in the pneumonia when there seems to be 



DISEASES OF THE LUNGS. 



755 



an excessive collateral congestion, cut cups are often very serviceable. 
They are especially useful when there is much pleurisy. Dry cups are 
often of value : like sinapisms and other rubefacient applications, they 
affect not the pneumonia itself, but the congestion of the lungs which 
surrounds the absolutely diseased part. Poultices are especially valuable 
in children. (See Catarrhal Pneumonia.) Blisters are of great service 
when there is pleurisy with the pneumonia, and sometimes may be 
advantageous in overcoming collateral effects of the disease. 

In the treatment of adynamic pneumonia it is essential to begin the 
use of stimulants very early and to push these remedies steadily through 
the disease in the largest doses that can be borne. Alcohol, digitalis, 
strychnine, cocaine, and atropine are the drugs upon which reliance must 
be chiefly placed. Musk has a certain limited value, and we have seen it 
apparently save life. As stated many years ago by Trousseau, it is espe- 
cially effective in the pneumonia of alcoholics. As most of the musk of 
the market is inert, the utmost care should be taken to get as pure an 
article as possible : if it does good in any individual case, it will quiet 
the delirious and nervous excitement and bring about sleep ; if it does 
not produce distinct effects, there is no use in continuing its adminis- 
tration. We have seen, as an example, a drunkard wildly delirious 
from pneumonia receive a rectal injection of fifteen grains of musk and 
pass into a quiet sleep of five or six hours' duration, during which time 
food was taken regularly, then awake furiously maniacal, to be again 
subdued by another dose of musk, until, thus tided over the period of 
greatest danger, the patient finally convalesced. 

In 1892, Klemperer instituted a series of experiments having for 
their object the treatment of pneumonia as an infectious disease by an 
antitoxin. It is affirmed that rabbits can be immunized against the pneu- 
mococcus, and in a number of cases human pneumonia has been treated 
by injection with the serum obtained from cases of pneumonia in man. 
The best result that has been claimed for the method is that it hastens 
very greatly the development of the crisis. In trials made in Philadel- 
phia with the treatment the effects of the injections were distinctly 
evil, and at present the method is simply in the stage of preliminary 
experiment 5 its use is not justified except for the purposes of research 
in the hands of experts. 

CHRONIC FIBROUS PNEUMONIA. CHRONIC INTERSTITIAL 

PNEUMONIA. 

Definition. — An obliteration of the lung- tissue due to the presence 
of an increased quantity of fibrous tissue of inflammatory origin. 

More or less confusion has resulted from the attempts to include under 
chronic interstitial pneumonia the terminal results of various pathological 
processes in which fibrous tissue is found in the lungs. It may grow 
from the alveolar wall or from the interstitial tissue, whether between 



756 



DISEASES OF THE RESPIRATORY APPARATUS. 



the lobules, beneath the pleura, or along the bronchi and blood-vessels. 
It is present often in small quantity and limited to a part of the lung, 
and again may be abundantly distributed over a lobe or throughout both 
lungs. This fibrous tissue forms a scar, filling the gap due to gangrene, 
abscess, the necrosis of tuberculosis, or the destruction of a gumma, or 
causes the obliteration of an atelectatic portion of the lung. It encap- 
sulates animal and vegetable parasites which have invaded the lungs, 
and becomes increased in the vicinity of the various tumors which de- 
velop in the lung. In chronic pleurisy it may extend from the inflamed 
pleura into the compressed lung and permanently prevent its expansion. 

New-formed fibrous tissue also may be distributed in greater or 
less abundance along the bronchi in the chronic bronchitis resulting 
from the continuous inhalation of irritating particles of dust in certain 
trades, the pneumonokoniosis of Zenker. The varieties of dust princi- 
pally concerned are coal-dust among workers in coal, causing anthr on- 
cosis, particles of steel among scissor-grinders and file-makers, causing 
siderosis, and bits of sand among stone-cutters, producing chalicosis. The 
inhaled dust enters the interstitial tissue of the lung, where it in part 
remains, and from which it in part is carried by means of the lymphatics 
both to the pleural surfaces and to the bronchial lymph-glands. Abun- 
dant dust produces increased weight and density of the lung and peculiar 
modifications of color, — black from coal, reddish yellow from iron or steel, 
and grayish white from sand. In chalicosis gritty particles may be felt 
with the knife on section of the lung. In consequence of the long-con- 
tinued inhalation of the dust, chronic bronchitis and interstitial pneu- 
monia take place. The thickened fibrous tissue is either diffused or dis- 
tributed in the form of nodules, the latter being due to the induration 
of lymph-follicles or to the transformation into fibrous tissue of the foci 
of broncho-pneumonia. Bronchiectasis and emphysema are also results. 
The patient suffers from chronic cough, with profuse expectoration and 
progressive emaciation. In anthracosis the sputum is especially charac- 
teristic, being of a constant dark-gray or black color from the presence 
of particles of carbon. In consequence of the chronic cough and persist- 
ent emaciation the cases have been grouped under phthisis, and desig- 
nated coal- miner's phthisis, scissor-grinder's phthisis, or miller's phthisis, 
according to the trade especially concerned. Pneumonokoniosis is es- 
sentially a severe chronic bronchitis due to a particular cause, and end- 
ing in bronchiectasis, emphysema, and fibrous pneumonia. It includes 
the conditions which, when extensively distributed, Corrigan described as 
cirrhosis of the lung. 

The term fibrous pneumonia, however, when used to characterize a 
disease, should be restricted to the rare termination of acute pneumonia 
in carnification instead of resolution, gangrene, or abscess. This con- 
dition was recognized by Laennec, but since his time has usually been 
overlooked. 



DISEASES OE THE LUNGS. 



757 



Etiology. — The etiology of genuine fibrous pneumonia is presumably 
that of acute fibrinous pneumonia, of which it represents a terminal stage. 
Little or nothing is known of the cause or causes of such a termination. 
It may be that other bacteria than the diploeoccus of pneumonia were 
concerned in the acute attack. Marchand suggests that previous disease 
of the lung, by causing induration and pleural adhesions, may interfere 
with the absorption of the fibrinous exudation of acute pneumonia and 
thus promote the formation of fibrous tissue. According to this observer, 
genuine fibrous pneumonia is to be found in persons addicted to alcohol, 
and in persons poorly nourished and in bad hygienic surroundings. 

Mokbid Anatomy. — The affected portion of the lung is distended, 
dense and heavy, and exceedingly resistant to pressure. The pleura is 
thickened and opaque. The cut surface of the lung is of a pale reddish- 
gray color, translucent, smooth, or slightly granular. Later in the dis- 
ease the color of the lung is still paler, and the cut surface shows numerous 
minute yellow specks, due to the fatty degeneration of the cells in the 
alveoli. The bronchi contain an opaque fluid, and there is a visible in- 
crease of the peribronchial fibrous tissue and that around the blood- 
vessels. The microscopic sections show a thickening of the alveolar wall 
and coherent, fibrillated casts resembling those of fibrinous hepatization, 
but composed of vascularized granulation- tissue. These are the altera- 
tions characteristic of carnijication, and in genuine fibrous pneumonia may 
be found as early as three weeks after the onset of the acute pneumonic 
symptoms. But little is known of the nature of the permanent alterations 
of the lung which are found in cases of apparent recovery. It is probable, 
however, that interlacing bands of fibrous tissue, obliterated alveoli, 
dilated bronchi, and vesicular emphysema are results of the process. 

We are indebted to Heller for our knowledge of a congenital fibrous 
pneumonia affecting symmetrically both lungs and due to syphilis. The 
fibrous tissue is diffused throughout the lungs, forming a coarse mesh- work 
by which the alveoli are narrowed. In consequence of this affection the 
child may die at or immediately after birth. If it survives, the right 
heart becomes hypertrophied. There is an especial liability to bronchitis 
and pleurisy, but the subject may reach adult life. 

Symptoms. — The symptoms at the outset of this variety of pneumonia 
in no way differ from those of typical pneumonia. The temperature 
even may fall at the usual time by crisis or lysis, but rapid breathing 
and cough persist, and the temperature soon rises one or two degrees, 
remaining elevated for weeks, although the appetite improves. The 
pulse is in the vicinity of 100, and there is a sero-purulent sputum. The 
physical examination of the chest shows that the dulness, bronchial 
breathing, and bronchophony caused by the hepatized lung continue, 
and, in addition, fine and coarse, moist and dry rales are to be heard 
over the affected region. These conditions persist with but little change 
for weeks and even months, when, in favorable cases, the fever slowly 



758 



DISEASES OF THE RESPIRATORY APPARATUS. 



disappears, the cough diminishes, and the patient improves in strength. 
There is usually a progressive shrinkage of the chest, but the disappear- 
ance of dulness and the return of broncho -vesicular breathing indicate 
that the function of the affected portion of the lung is more or less com- 
pletely restored. In other cases there are persistent cough, shortness of 
breath increased on exertion, and hypertrophy of the right side of the 
heart, perhaps eventually followed by failing compensation, as indicated 
by the occurrence of cyanosis and oedema. It is not unlikely that in 
this series of cases are to be included certain of those designated fibroid 
phthisis. 

Diagnosis. — Clinically the condition is one of acute pneumonia in 
which the symptoms persist. The most common cause of such a per- 
sistence is the tuberculous nature of the pneumonia, but the absence of 
bacilli in the sputum negatives this diagnosis. The physical signs fre- 
quently continue for a number of weeks in the delayed resolution of 
fibrinous pneumonia, but the symptoms early disappear and the patient 
progressively improves. 

Prognosis. — Death may occur during the early weeks of this disease, 
although recovery is the rule. Permanent disability, however, ensues. 
The patient is liable to frequent or persistent bronchitis, and may suffer 
from the symptoms of bronchiectasis. The greater the destruction of the 
lung the more considerable is the hypertrophy of the right side of the 
heart, which may eventually prove the cause of death from failing com- 
pensation. 

Treatment. — In the early stages of chronic fibrous pneumonia the 
most earnest efforts should be made to maintain the nutrition of the 
patient by the careful use of regulated exercise, out- door life, high feed- 
ing, and tonics, at the same time every precaution being taken by warm 
underclothing to prevent suffering from cold. Cod-liver oil and whiskey 
given together may be of great service. Mild prolonged counter- irritation 
when judiciously used is of value, probably by relieving rather the 
accompanying catarrh than the condition of the lung. Croton oil is per- 
haps the most manageable agent. Creosote, the expectorant volatile oils, 
and terebene are often temporarily useful, especially when there is much 
secondary catarrh. Narcotics are sometimes necessary to control cough. 
(See Acute Bronchitis.) The long- continued use of small doses of arsenic 
(one drop of Fowler's solution three times a day) distinctly benefits many 
cases. Potassium iodide (five to ten grains a day) and corrosive sublimate 
(one-fortieth to one- seventieth of a grain three times a day) may be used 
continuously between courses of arsenic, to aid in the absorption of 
fibrinous exudate. 

In the later stages of chronic fibrous pneumonia, however, the most 
satisfactory results are undoubtedly to be obtained by climatic treatment, 
associated with the institution of such measures as are best fitted to pro- 
duce bodily vigor. We have seen solidification of the lung, believed to 



DISEASES OF THE LUNGS. 



759 



be due to fibrous pneumonia, disappear after six months' residence in a 
high and dry locality. The management of the case, and the precautions 
to be taken, are entirely similar to those which have been discussed in 
detail under the head of Phthisis Pulmonalis. Even if far distant from 
the medical adviser the patient should during this period use arsenous 
acid in some form, in such minute dose as to be incapable of irritating 
the gastro-intestinal mucous membrane whilst at the same time pre- 
serving the power of affecting the general nutrition. 

BRONCHO-PNEUMONIA. 

Definition. — Circumscribed inflammation of the lung, usually mul- 
tiple, secondary to a capillary bronchitis with which it is associated. 

Etiology. —Broncho-pneumonia is chiefly due to the inhalation of 
irritating material, especially that containing bacteria. A bronchitis 
results, which is continued into the capillary bronchi and thence into the 
alveoli. Numerous bacteria are concerned, foremost among which is the 
bacillus of tuberculosis, but the bacillus of diphtheria, the influenza 
bacillus, Friedlander's bacillus of pneumonia, the diplococcus of pneu- 
monia, streptococci, and staphylococci are also of etiological importance. 
The effect of the bacteria is intensified by the associated inhalation of 
coarser material, as the secretions from the throat in diphtheria, particles 
of food in feeding through the tube, the vomitus in exhausted or uncon- 
scious persons, blood in case of extensive hemorrhage into the respiratory 
tract, particles of dust in various trades, and irritating gases. The en- 
trance of such irritating material into the smaller bronchi is promoted 
by causes interfering with the closure of the glottis, as ulceration, tumors, 
central or peripheral paralysis, by violent paroxysms of coughing, as in 
whooping-cough, and by the enfeebled or unconscious state of the patient 
in anaesthesia, intoxication, or severe disease. The inflammatory action 
of the bacteria in the lungs is furthermore increased by the persistent 
local congestion and oedema of frequent occurrence in typhoid fever and 
other acute and chronic diseases in which weakened circulation and pro- 
longed confinement to bed are constant conditions. Broncho-pneumonia 
is of greater frequency at the extremes of life, and during the winter 
months, and not uncommonly follows directly exposure to cold. 

Morbid Anatomy. — The changes characteristic of broncho-pneumonia 
are disseminated in nodules or lobules, which may be agglomerated or dif- 
fused over a considerable portion of a pulmonary lobe. They consist of 
an exudation of serum, fibrin, leukocytes, occasional red blood- corpuscles, 
and desquamated epithelium, which fills the bronchioles and the adjacent 
alveoli. The neighboring interstitial tissue is largely infiltrated with 
leukocytes. In nodular broncho -pneumonia the individual foci vary in size, 
and may be as large as the tip of the little finger. Their presence is often 
indicated by a shot-like feel in the unopened lung. On section the affected 
portions of the lung are slightly elevated^ dark red or reddish gray, resist- 



760 



DISEASES OF THE RESPIRATORY APPARATUS. 



ant, and yield on pressure a reddish-gray or pnriform viscid fluid, which 
usually escapes from the section of a central bronchus. Groups of nodules 
frequently are closely clustered in consequence of the limitation of the 
broncho-pneumonia to the branches of a particular bronchus. In lobular 
bronclio-pneumonia the affected portions of the lung are wedge shaped, 
and the base of the wedge is often to be seen beneath the pleura as a 
slightly elevated, dark- red, polygonal patch, the surface of which is cov- 
ered with a delicate, fibrinous membrane. When the nodules and lob- 
ules are numerous and closely agglomerated the intervening lung tissue 
is often injected, ©edematous, and somewhat collapsed. In both nodular 
and lobular broncho-pneumonia the neighboring portions of the lung are 
frequently in a condition of collateral emphysema. The broncho-pneu- 
monic nodules resulting from the inhalation of food rapidly become gan- 
grenous, and then are soft, almost diffluent, and of a dark-green color. 
Abscesses also follow the inhalation of food, either as a primary effect or 
from the establishment of an inflammatory line of demarcation around 
a gangrenous centre. In tubercular broncho-pneumonia necrosis of the 
nodule results, and the familiar characteristics of cheesy degeneration are 
j)roduced. All varieties of broncho-pneumonia may end in resolution or 
in permanent obliteration of the alveoli, manifested by a localized indu- 
ration and pigmentation of the non-aerated lung. 

Symptoms. — The symptoms of broncho-pneumonia result from the 
mechanical obstruction to the air-passages and from the absorption of 
toxins from the diseased portions of the lung ; the severity of the symp- 
toms is dependent largely upon the number of foci present. Since bron- 
cho-pneumonia is usually a secondary condition, following the course of 
a bronchitis, the symptoms at the outset are generally those of a bron- 
chitis gradually or suddenly increasing in severity and extending into 
the capillary bronchi. The extension of the capillary bronchitis to 
the alveoli is indicated by exacerbation of the fever, dyspnoea, and 
cough. Pain is inconstant, since pleurisy accompanies only when the 
nodules are superficial. The temperature remains continuously elevated 
in the vicinity of 103° F., and is without typical curve. The higher and 
more prolonged the elevation of temperature the more probable are nu- 
merous foci of inflammation. The elevation of the pulse and respiration 
is in proportion to that of the temperature, and, particularly in children, 
the pulse may reach 150 and the respirations be upward of 60 per minute. 
The dyspnoea is marked, the accessory muscles of respiration being called 
prominently into play, and the breathing is short and quick, often irreg- 
ular from fear of exciting cough and pain and wheezing from the presence 
of coarse rales in the larger tubes. Cough is frequent, distressing, and in 
paroxysms. In children the efforts at coughing are likely to cause vom- 
iting, and the bronchial secretion which has been swallowed is to be found 
in the ejected contents of the stomach. The cough may be so violent that, 
in connection with the dyspnoea, rupture of the alveolar wall takes place, 



DISEASES OE THE LUNGS. 



761 



and interstitial emphysema of the lung follows, at times being extended 
from the root of the lung into the subcutaneous tissue of the neck and 
chest. The sputum is usually scanty, viscid, and streaked with blood, 
and the urine frequently contains a trace of albumin. 

On physical examination of the chest the conspicuous signs at the out- 
set are those of a bronchitis extending into the smaller tubes. Eesonance 
on percussion may be somewhat increased, and numerous coarse and fine, 
dry and moist rales are to be heard. If the broncho-pneumonic nodules 
are large and superficial, which is especially likely to be the case when 
there are numerous nodules in the posterior portion of the lower lobes, 
sharply defined signs of solidification may be found, as dulness, bronchial 
breathing, and bronchophony. 

The course is usually protracted, even in favorable cases extending 
over a fortnight, the temperature gradually falling to the normal as the 
dyspnoea and cough diminish. In unfavorable cases the skin becomes 
dusky, and the expression anxious, until sopor occurs, interrupted perhaps 
in children by convulsions, and ending, often suddenly, in death. In such 
cases the fatal termination may occur early, as in fibrinous pneumonia 
from acute congestion and cedema, or late in the course of the disease from 
complicating pulmonary gangrene or abscess. Convalescence from bron- 
cho-pneumonia, especially in children, is not infrequently protracted 
over a period of months, during which slight and irregular elevations of 
temperature are frequent, and at such times the respiration is quickened 
and moist rales are to be heard. It is in these cases in particular that 
infection with the bacilli of tuberculosis is to be feared and especially 
guarded against. 

Diagnosis. — Since broncho-pneumonia is the result of a capillary 
bronchitis, and the pulmonary lesions are often so small or so situated 
as to give no physical evidence of their presence, the diagnosis of broncho- 
pneumonia is chiefly based upon the persistence of the symptoms and 
signs of a capillary bronchitis. Dyspnoea, frequent, short, dry cough, 
high fever, and abundant, fine moist rales in a resonant lung in the 
course of acute bronchitis are suggestive of a capillary bronchitis or 
bronchiolitis. The longer the symptoms and signs continue, the more 
probable is the presence of foci of broncho-pneumonia, which may form, 
in the course of two or three days, with a rapidity equal to that of the 
solidification of the lung in acute fibrinous pneumonia. This disease is 
to be excluded by the absence of a sudden onset and the well-marked 
physical signs. Central pneumonia, in which the physical signs of solidi- 
fication may be obscured, lacks the numerous fine moist rales of the 
capillary bronchitis associated with broncho-pneumonia, and rusty sputa 
may be present. Sharply defined broncho-pneumonia, especially when 
occurring as a nodule of lobular pneumonia, is not infrequently due to 
the bacillus of tuberculosis, the presence of which is to be suspected if 
the symptoms and signs have persisted for several weeks. Even if char- 



762 



DISEASES OF THE RESPIRATORY APPARATUS. 



aeteristic bacilli are not found in the sputum, a chronic sharply defined 
patch of broncho-pneumonia is to be regarded with anxiety, since, if not 
tuberculous at the outset, it readily becomes so. 

Prognosis. — The general mortality from broncho-pneumonia is high, 
perhaps from one-third to one- half of the cases proving fatal. It varies 
considerably, however, under the conditions of its occurrence. In infants 
it is often associated with diphtheria, measles, or whooping-cough, and 
the death-rate is large. In old people also the mortality is high. When 
broncho-pneumonia is due to the inhalation of foreign bodies of any con- 
siderable size, and especially to the entrance of food, death is the usual 
result. In the broncho-pneumonia following measles in children other- 
wise healthy, or occurring as an epidemic in them or in adults, the dis- 
ease runs a favorable course. A sharply defined broncho-pneumonia, even 
if the course is protracted and the origin tuberculous, not infrequently 
ends in recovery. In any particular case the prognosis depends upon 
the extent of the disease, the age and the previous health of the patient, 
and the exciting cause. The unfavorable symptoms are the persistence 
of high fever, irregular and superficial respiration, rapid, weak pulse, 
drowsiness, and delirium. 

Treatment. — It is especially important to have skilful and watchful 
nursing, in order to keep the child at absolute rest, and to note and 
report at once the development of sudden serious symptoms, such as a 
rise of temperature or the development of dyspnoea or cyanosis. The 
food should consist chiefly of animal broths, which may often be thick- 
ened with nutritive material, or an egg may be stirred into the soup 
whilst still very hot. The white of egg dissolved in water and sweetened 
to the taste of the child is useful especially for diluting alcoholic stimu- 
lants, which are often required very early. The room should be kept 
at an even temperature of about 65° F., free from draughts, with a well- 
moistened air. 

The indications which underlie the medical treatment of capillary 
bronchitis differ from those of ordinary bronchitis chiefly as required 
to meet the tendency which exists, especially in the advanced stages of 
the disease, to cardiac failure. Grave danger, therefore, even in the be- 
ginning of the disease, attends the use of depressing remedies. It is not 
justifiable to give to the child suffering from broncho-pneumonia such 
drugs as veratrum viride or tartar emetic, although in the beginning 
of the attack the potassium citrate cough mixture with ipecacuanha, or, 
in the robust child, with apomorphine, should usually be exhibited. If, 
as is frequently the case, the temperature is high, its reduction is most 
urgently demanded on account of its weakening influence upon the right 
heart. It is plain that aconite must be employed, if at all, with the 
greatest caution, and even phenacetin and its allies are to be looked upon 
with disfavor, except in small doses, on account of their occasional cardiac 
effects. The tepid bath, 90° F., usually affords the safest method of 



DISEASES OF THE LUNGS. 



763 



keeping down the fever, especially if it be aided by the application of 
cold compresses to the chest. 

In Germany much reliance is placed upon the use of tepid packs. 
The naked child is wrapped in a sheet which has been wrung out of 
water having a temperature of about 75° F., and then in a dry woollen 
blanket. When the heart is weak, very cold baths are dangerous. (See 
page 142.) 

Stimulant expectorants are usually indicated more early in capillary 
than in ordinary bronchitis. Ammonium chloride is especially valuable, 
to be preferred, we think, to ammonium carbonate, which is so much 
used by practitioners, but which in whole or in part undergoes decom- 
position in the stomach. The ammonium should be given every hour 
during the day and every two or three hours at night. A little later 
in the disease oil of eucalyptus and terebene are often of great service ; 
but the employment of any expectorant should always be subordinate to 
its effects upon the stomach. 

What has been said concerning the use of counter- irritation in acute 
bronchitis applies with equal force to broncho-pneumonia. In very 
young children moist applications, the jacket-poultice or cold compresses, 
as may be selected, are much more effective than in adults. It appears 
probable that the absorption of water may take place through the thin- 
walled chest, so as to exert a local soothing influence upon the internal 
organs. In children blisters must be employed with great caution, if 
at all. When the broncho-pneumonia is part of a general infectious 
process they are especially dangerous ; their excessive local effects may 
become a serious complication. There are, however, cases in which 
they may be serviceable if used with due judgment. 

It is believed by many practitioners that the free use of water has 
a pronounced tendency to lessen the viscidity of the inflammatory pro- 
ducts in the bronchial tubes : hence the child should be encouraged to 
drink copiously of watered milk, plain or effervescent waters, or weak 
lemonade. 

In young children capillary bronchitis frequently produces death by 
the accumulated secretion mechanically interrupting the lung- function. 
A slight insufficiency of respiration may bring about a slow accumulation 
of carbonic acid, which more and more depresses respiration. In many 
cases it is dangerous to allow a child to sleep longer than three hours 
without being thoroughly awakened, and we have seen cases in which 
it was necessary to arouse the child every twenty minutes, and even to 
produce a crying-fit, in order to clear off the excessive carbonic acid. 
It will be readily seen that opiates are, therefore, to be used for the 
relief of the pleuritic or other pain only with the greatest reserve, and 
that whenever there is a tendency to stupor, with lividity of the face 
and lips, or even a general cyanosis (suffocative catarrh), it is essential 
not only to support the respiratory centres by hypodermic injections of 



764 



DISEASES OF THE RESPIRATORY APPARATUS. 



strychnine and cocaine, but to free the lungs from retained secretion by 
vomiting. Zinc sulphate or mustard should be selected as the emetic, 
even ipecacuanha and apomorphine being too depressant to be used with 
freedom, though they may be employed as adjuvants if necessary. When- 
ever there is cyanosis and the child is old enough to be docile, frequent 
inhalations of pure oxygen should be given. 

In young children suffering from capillary bronchitis and broncho- 
pneumonia, after the entire failure of emetics to clear the lungs, when 
the narcosis was so deep that the power of swallowing was lost and death 
seemed inevitable, we have saved life by the following procedure. Three 
tubs having been provided, one emptj^, one full of water at about 110° F., 
one full of very cold ice- water, the child's body is to be held over the 
empty tub and a ladleful of the hot water dashed upon the chest, imme- 
diately followed by one of the ice-water, so as to produce a violent respi- 
ratory spasm, by which the air is drawn into the lungs. If after the 
douches have been repeated a number of times change of color of the 
surface of the body shows that the accumulated carbonic acid has been in 
part thrown off and that consciousness is returning, the whole body may 
be immersed in the water, which is so hot that the child screams, and 
thereby fills its lungs with air. The use of the ladleful of hot water in 
these cases is to intensify the shock and to prevent cooling of the body. 

PULMONARY GANGRENE. 

Etiology. —Gangrene of the lung, as of other parts, is due to the 
action of putrefactive bacteria upon the tissues whose nutrition has been 
impaired or arrested by an interference with the supply of blood. It is 
to be found, therefore, in inflammation as fibrinous pneumonia, broncho- 
pneumonia, especially when due to the inhalation of food, and in con- 
nection with cavities, whether of tubercular or of bronchiectatic nature. 
The disturbance of nutrition may be the result also of injury and of 
embolism. Putrefactive bacteria may be present in the affected portion 
of the lung before its nutrition is disturbed, or enter in the inhaled food 
or through a fistulous communication between the alimentary and respi- 
ratory tracts, or be introduced in an embolus from a gangrenous source. 

Pulmonary gangrene is of more frequent occurrence in those enfeebled 
by age, bad habits, or disease than in vigorous persons of good habits in 
the prime of life. 

Morbid Anatomy. — The anatomical appearances are oftenest present 
in the lower lobes, are usually circumscribed, single or multiple, but in 
rare instances are diffused over the greater part of a lobe. The multiple 
nodules and diffused gangrene are frequently due to the dissemination of 
the gangrenous products from the primary focus along various bronchi by 
inhalation. At the outset the diseased portion of the lung appears as 
a more or less sharply defined mass of various size, irregularly rounded, 
of extremely offensive odor, and of a cl ark-green color. It is friable, and 



DISEASES OF THE LUNGS. 



765 



soon becomes deliquescent. The fluid is easily washed away, leaving a 
cavity filled with shreds of tissue adherent to the wall. The surrounding 
lung- tissue is hepatized, and the necrotic and putrefactive changes are 
often continued in it until the cavity progressively increasing in size 
becomes as large as the fist. The pleura, if reached, is perforated, and 
an ichorous pneumothorax results. Abscess of the brain, presumably 
of embolic origin, is an occasional complication. 

Symptoms. — Fever, cough, fetid sputa, and foul breath are the prom- 
inent disturbances in pulmonary gangrene, and are of rapid or gradual 
onset according to its especial causation. The fever is constant, the range 
of temperature shows irregular variations, and the pulse is quick and 
feeble. There is no appetite, vomiting and diarrhoea are frequent, and 
there is rapid loss of flesh and strength. Cough occurs at irregular 
intervals, is frequently paroxysmal, and results in the raising of abundant 
liquid sputum resembling that of putrid bronchitis with bronchiectasis. 
After standing the upper portion is frothy, the middle layer thin and 
discolored, and the lower portion, of a dirty-brown color, contains fat- 
crystals, bacteria, and shreds of lung-tissue in which, during the advance 
of the gangrene, elastic fibres are to be found. Blood is present frequently 
in the sputum, usually in small quantity, and produces a green or brown 
coloration of the fluid and forms granular pigment in the sediment. 
Profuse and even fatal hemorrhage may occur from the sudden rupture 
of a large blood-vessel in the gangrenous tissue. The physical signs at 
the outset are those of consolidation, but soon yield to those of a cavity, 
and are often overlooked if the gangrenous disturbances are of small 
area or deep-seated in the lung. 

Exacerbation of the temperature and the simultaneous development 
of a sharp stitch-like pain in the side indicate a complicating pleurisy 
which is likely to prove purulent. Sudden dyspnoea accompanied by a 
tearing sensation is evidence of a rupture of the pleura overlying the 
gangrenous cavity and of the passage of air into the thorax, in which 
case pneumothorax and ichorous pleurisy are soon followed by death. 
Frequently the progress of the gangrene is arrested by the formation of 
a granulation-tissue in the inflamed lung surrounding the affected por- 
tion, and then the disease assumes a chronic course, the symptoms being 
those of a putrid bronchitis, and eventually, perhaps, of a bronchiectasis. 
If the destruction of lung is of small area, these symptoms may cease in 
the course of months and the cavity be obliterated by the formation of 
a scar. 

Diagnosis. — The presence of pulmonary gangrene is to be inferred 
during the acute stage by the rapid production of the abundant offensive 
sputa containing elastic fibres in connection with the etiological factors 
above mentioned. In the chronic stage it is easily confounded with 
putrid bronchitis, especially as shreds of lung- tissue may no longer be 
found in the sputum. Putrid bronchitis, however, occurs in the course 



766 



DISEASES OF THE RESPIRATORY APPARATUS. 



of long- continued chronic bronchitis, while gangrene of the lung is 
commonly of acute onset. 

Prognosis. — Although recovery from gangrene of the lung is pos- 
sible when a small portion only of the lung is involved, the prognosis 
in general is unfavorable. Death is caused usually by acute or chronic 
septicemia, and in rare cases is attributable to cerebral abscess. In 
other instances the course is that of pulmonary abscess. 

Treatment. — It is not possible in any way by medicinal treatment to 
affect gangrenous lung- tissue. Creosote may be used internally as freely 
as it can be taken, and inhalations of carbonic acid or other disinfectant 
vapors or sprays steadily practised ; but there is no reason for believing 
that these measures have any curative effect. The general treatment 
should, of course, be stimulating and supporting to the fullest extent. 
"When a limited area of the lung is affected, and is so situated as to be 
reached surgically, pneumotomy may be performed, as successes have 
been achieved. 

PULMONARY ABSCESS. 

Definition. — A circumscribed cavity in the lung with a wall of 
inflamed pulmonary tissue and with purulent contents. 

Etiology. — The presence of pyogenic bacteria is the immediate cause 
of pulmonary abscess, and the conditions favoring their growth are pro- 
moted by the exciting causes, — namely, trauma, inflammation, and embo- 
lism. The bacteria may be dormant in the lung previous to the approach 
of the exciting cause, or may be admitted with it, for example, in a 
septic embolus, or in inhaled food, or be introduced from a suppurating 
process in the vicinity, especially in the pleural or the peritoneal cavity, 
or from abscess of the liver, mediastinum, or peribronchial lymph-glands. 

Morbid Anatomy. — The abscesses are solitary or multiple, the latter 
being due especially to embolism or food-inhalation. The solitary variety 
is found more frequently in the upper lobes, but multiple abscesses are 
seated oftener in the posterior portion of the lower lobes. Multiple 
abscesses are usually small, not larger than the finger-tip, rounded, 
deep-seated, or superficial. In the early stage they appear as sharply 
localized purulent infiltrations of the lung-tissue, and the pus may be 
squeezed from the cut surface as from a sponge. Later the cavity is 
sharply defined, its wall of an opaque, yellowish- gray granulation-tissue 
separated from the aerated lung-tissue by a hepatized zone. The largest, 
usually solitary, abscesses may be of the size of the fist, and have a 
relatively smooth wall surrounded by indurated lung-tissue. When the 
pleura forms a part of the wall of the abscess a fibrinous or suppurative 
pleurisy and perhaps pneumothorax are associated. 

Symptoms. — In the clinical consideration of pulmonary abscess an 
important distinction to be drawn is that between acute and chronic 
abscess. Acute abscesses when multiple are small, and are formed usually 
without any characteristic symptoms, since they occur as complications 



DISEASES OF THE LUNGS. 



767 



of other morbid processes. The presence of a large acute abscess may be 
made manifest towards the close of hepatization in acute pneumonia by 
the sudden evacuation of a considerable quantity of pus in which blood- 
crystals and elastic fibres are to be seen. 

Chronic pulmonary abscess is indicated by persistent cough, by 
abundant expectoration, and by the physical signs of a cavity. The 
sputum may contain shreds of lung-tissue, also crystals of cholesterin. 

The acute abscess is to be distinguished from gangrene by the greater 
quantity of pus in the sputum and the less offensive odor. In chronic 
abscess the freedom from characteristic bacilli serves to eliminate a tuber- 
cular cavity, and the absence of antecedent chronic bronchitis and the 
presence of elastic fibres in the sputum exclude bronchiectasis. 

The prognosis of abscess of the lung is serious. A large acute abscess 
may cause death from suffocation if the pus suddenly enters a large 
bronchus and is inhaled into its branches. Eupture of the abscess into 
the pleural cavity usually produces a fatal pyopneumothorax. Pulmo- 
nary abscess may heal, however, and the sac become obliterated either 
spontaneously or after evacuation through the chest- wall. 

Treatment. — There is no known medical method of successfully in- 
fluencing pulmonary abscesses. The general treatment must be support- 
ing and palliative. If the abscess be superficial, pneumotomy should be 
performed, with thorough after- drainage. 

TUMORS OF THE LUNG. 

Tumors of the lung occasionally occur, but usually are not sufficiently 
large or numerous to give rise to symptoms. Primary and secondary 
growths are to be found. The former include fibroma, which is gener- 
ally small, often multiple, and then in origin on the border-line between 
inflammation and new formation, and lipoma, chondroma, and osteoma, 
which are rarities. These tumors are benignant, although they may pro 
duce disturbance of respiration by pressure upon the lung or the larger 
air-passages. The malignant tumors are malignant lymphoma, sarcoma, 
and cancer. From their essentially similar clinical characteristics they 
are conveniently grouped under Cancer of the Lung. 

CANCER OF THE LUNG. 

Etiology. — Malignaut tumors of the lung, though often found as sec- 
ondary growths, sometimes originate in this organ, and cancer is present 
as a primary tumor more often than the other varieties. Sarcoma and 
malignant lymphoma are usually secondary either to disease, especially 
of the lymph-glands, in the vicinity, or to a primary growth in remote 
parts of the body. Secondary cancer of the lung is more common in 
women than in men, perhaps from the frequency of extension to the lung 
through the intervening pleura of cancer of the mammary gland, so 
common in women. The frequent occurrence of malignant lymphoma in 



768 



DISEASES OF THE RESPIRATORY APPARATUS. 



the cobalt-mines of the Tyrol, as described by Wagner, is used in support 
of a local, perhaps infectious, cause of malignant neoplasms. 

Morbid Anatomy. — The malignant disease of the lung is to be found 
as nodules or as a diffuse infiltration ; when primary it is limited to a 
single lobe or to one lung, but when secondary is usually bilateral. The 
nodules are solitary or multiple, and vary in size from a pin's head to a 
mass as large as the fist. Large solitary nodules are likely to be sharply 
defined, whereas large multiple nodules are often gradually continued 
into the lung- tissue. The nodules are irregularly distributed throughout 
the lungs, and are usually more abundant in the lower lobe. Infiltrating 
cancer follows the course of the bronchi, and may so grow within the 
smaller bronchi and alveoli as completely to close them, although on 
microscopical examination the elastic fibres in the alveolar wall remain in 
normal grouping. Cancer of the lung is usually soft, medullary, and of a 
grayish color. An opaque juice is to be squeezed from the cut section, 
and is composed largely of epithelioid cells often fattily degenerated. The 
growth sometimes projects into the larger bronchi as nodules, rounded 
or flattened, and occasionally with a villous surface. When the tumors 
grow from the pleura, they are not infrequently associated with hydro- 
thorax or pleurisy, the latter at times of hemorrhagic character. The 
lymph -glands at the root of the lung, in the neck, and even at remote 
parts of the body are often simultaneously diseased. 

Symptoms. — When the tumors of the lung are of sufficient size or so 
situated as to produce symptoms, dyspnoea is usually the first and most 
frequent disturbance. Perhaps at the outset it is manifested only on ex- 
ertion, but it is at times paroxysmal, and occasionally stridulous, espe- 
cially when the root of the lung is involved. Cough is frequent, often 
dry, but sometimes accompanied by a viscid sputum compared from its 
color to the juice of black currants. There may be no pain, or stitch- 
like pains are present when there is inflammation of the pleural surface, 
which is of occasional occurrence only, having been present, according to 
Bennett, in six out of thirty- nine cases. Fever is usually absent unless 
there is a complicating broncho-pneumonia. Digestive disturbances are 
infrequent, and loss of flesh and strength is often inconspicuous. On 
physical examination the face is either pale or livid : in the latter case 
pressure upon the veins at the base of the neck from the extension of 
the disease to the mediastinal lymph- glands is probable, and oedema as 
well as cyanosis of the face and of the upper half of the body is likely 
to be present. Persistent dulness on percussion, bronchial breathing, 
crepitant or subcrepitant rales, and bronchophony are to be observed. 
The abnormal respiratory and voice sounds not infrequently disappear 
in consequence of the accumulation of fluid in the pleural cavity or from 
the filling of the bronchi and alveoli with the cancerous growth. 

Diagnosis. — The existence of cancer of the lung is to be inferred from 
the persistent dyspnoea and the results of the physical examination of 



DISEASES OF THE LUNGS. 



769 



the chest, including the aspiration of a bloody fluid from the pleural 
cavity. The diagnosis is aided by the discovery of enlarged lymphatic 
glands at the base of the neck and by evidence of venous pressure in this 
region, and is strengthened if within a year or two a malignant tumor has 
existed elsewhere in the body. Pulmonary tuberculosis is to be elimi- 
nated by the absence of bacilli in the sputum, and broncho-pneumonia by 
the persistence of the symptoms in the absence of fever. Simple pleurisy 
is to be excluded by the rapid return of a serous or bloody fluid and by 
the failure of aspiration to give relief. 

Prognosis. — Cancer of the lung proves at times rapidly fatal, even 
within a few weeks after the symptoms have been complained of. Death 
occurs within a year from the onset of the disturbances. 

Treatment. — Relief from symptoms is the only result to be expected 
from treatment. Frequent examinations of the chest are to be made, 
since distress due to the presence of fluid is often relieved by paracen- 
tesis, which is to be repeated as often as may be necessary. 



40 



770 



DISEASES OF THE RESPIRATORY APPARATUS. 



CHAPTEE III. 

DISEASES OF THE PLEURA AND OF THE MEDIASTINUM. 

DISEASES OF THE PLEURA. 

PNEUMOTHORAX. 

Definition. — The presence of air in the pleural cavity. 

Etiology. — Air enters the pleural cavity in consequence of perfora- 
tion of the parietal or of the visceral pleura. The parietal pleura is per- 
forated by penetrating wounds of the thoracic wall from either accident 
or malice, and sometimes for therapeutic purposes, as in thoracentesis or 
thoracotomy. The spontaneous evacuation of pus through the thoracic 
wall in empyema is followed by pneumothorax. The air may enter when 
the diaphragm is perforated by subphrenic abscesses communicating 
with the alimentary canal and in the progress of ulcer or cancer of the 
stomach. Air may be admitted also through the parietal pleura in rup- 
ture, perforating ulcer, or cancer of the oesophagus. The pulmonary 
pleura may be perforated from the free surface in injury from a stab or 
from a broken rib, or in consequence of the evacuation into a bronchus 
of the pus in empyema. More frequently the perforation is due to de- 
struction of the pleura from the pulmonary side, particularly when there 
is a cavity due to pulmonary tuberculosis, gangrene, or abscess. Eupture 
of the pleura from within may occur also from sudden and violent mus- 
cular effort, especially when the lung is emphysematous. In more than 
nine-tenths of all cases, according to Fraentzel, pneumothorax is due to 
pulmonary tuberculosis, and, according to Weil, it occurs in nearly ten 
per cent, of cases of phthisis. 

Morbid Anatomy. — The immediate result of the admission of air 
into the pleural cavity is the retraction of the lung, in virtue of the 
shrinkage of its elastic tissue. The degree of contraction is dependent 
upon the presence or absence of solid material within the lung, or of 
adhesions between the pleural surfaces. If these are present, a circum- 
scribed pneumothorax follows, but if there is neither solidification of the 
lung nor pleural adhesions the pneumothorax is diffused and the entire 
lung is collapsed and is withdrawn to the upper and posterior portion of 
the chest. The heart and mediastinal tissues are displaced towards the 
unaffected half of the thorax, the diaphragm is depressed, and the liver 
also, in case of pneumothorax of the right chest. The hole in the pleura 
may be readily recognized, or may be seen with difficulty, especially 
in emphysema and in pulmonary tuberculosis. Inflation of the lung 
placed under water often reveals the situation of the opening by the 



DISEASES OF THE PLEURA. 



771 



escape of bubbles of air. "Weil discriminated between open pneumo- 
thorax, closed pneumothorax, and valvular pneumothorax. In open 
pneumothorax the air freely enters and leaves the pleural cavity. In 
closed pneumothorax the opening in the pleura becomes closed, and no 
more air enters. In valvular pneumothorax, which is the variety oftenest 
present, air is permitted to enter, but is prevented from escaping, and in 
consequence extreme degrees of deformity of the thorax and dislocation 
of its contents are occasioned. 

The anatomical changes in pneumothorax depend also upon the simul- 
taneous or subsequent admission of other material than air. Such mate- 
rial is usually infectious and causes pleurisy, which is serous, suppura- 
tive, or ichorous, and hydropneumothorax or pyopneumothorax results. In 
such cases, in addition to the collapse of the lung and the displacement 
of the organs, the pleura presents the characteristics of an acute or a 
chronic pleurisy, and the pleural cavity contains, in addition to air, a 
greater or less quantity of sero-fibrinous, purulent, perhaps hemorrhagic, 
exudation, which may have a putrid odor. 

Symptoms. — In diffused pneumothorax there are sudden pain, often 
of a tearing character, dyspnoea, which may be extreme and accompanied 
by cyanosis, anxiety, a feeble pulse, and even a condition of collapse. 
In circumscribed pneumothorax the adhesions may be so abundant, or 
the solidification of the lung so considerable, that few or no symptoms 
arise, and not infrequently the pleural cavity is found unexpectedly to 
contain air at the post-mortem examination of a case of extensive pul- 
monary tuberculosis. When pneumothorax is caused by the discharge 
through a bronchus of pus from a pleural cavity, there is, in addition to 
the above-mentioned symptoms, a sudden paroxysm of cough, associated 
with a greater or less quantity of purulent expectoration. 

On physical examination, the more extreme the degree of pneumo- 
thorax the more distended and the less movable is the affected half of the 
chest, the wider are its intercostal spaces, and the greater is the displace- 
ment of the heart and, in case of right-sided pneumothorax, of the liver, 
the lower edge of which may be found near the navel. There may be no 
dislocation of these organs, and in open pneumothorax the walls of the 
chest move on inspiration. On palpation vocal fremitus is absent. On 
percussion the resonance has a metallic character, and the pitch is higher 
when the mouth is open. It is usually tympanitic, perhaps amphoric, 
though at times it is dull, presumably in consequence of the extreme 
tension of the contained air. On auscultation the vocal resonance has a 
faint metallic sound, but may be absent, especially over the lower portion 
of the chest. The respiratory murmur often has also a metallic character. 
It is best heard at the upper part of the chest and in the back, and is 
faint and bronchial when there is marked compression of the lung. In 
open pneumothorax the breathing may be distinct and amphoric. An 
important characteristic of pneumothorax is the peculiarly modified 



772 



DISEASES OF THE RESPIRATORY APPARATUS. 



metallic sound to be heard at the back of the affected half of the chest 
when the edge of a coin is sharply struck against the flat surface of 
another in close apposition to the chest- wall in front. When fluid also 
is present it moves about with great freedom, and the resulting dull area 
on percussion quickly changes with the change of position. A splashing 
sound is to be heard often at a distance from the patient when he shakes 
his body, or when it is shaken. A metallic tinkling is frequently to be 
heard, especially when a long breath is drawn, and is attributed to the 
falling of material into the pleuritic exudation. 

Diagnosis. — Diffused pneumothorax is easily recognized on physical 
examination of the patient. The accession of fluid is made evident by 
splashing on succussion and by the ready change in the outline of dul- 
ness on change of position. Circumscribed pneumothorax is at times 
with difficulty differentiated from a large pulmonary cavity, but in pneu- 
mothorax the vocal fremitus and the respiratory murmur are dimin- 
ished or absent, while they are present and perhaps exaggerated in the 
examination of a cavity. Circumscribed pyopneumothorax is distin- 
guished also with difficulty from subphrenic pyopneumothorax. In the 
latter the previous history is of disease of the abdominal organs and 
not of the lungs. There is but little distention of the chest. Yocal fre- 
mitus and vocal resonance are distinct, perhaps loud, in the upper part 
of the chest, and are to be recognized somewhat lower on deep inspi- 
ration. 

Prognosis. — In unilateral pneumothorax from a wound or in con- 
sequence of extreme muscular strain, and when independent of acute 
or chronic inflammation of the lung, the prognosis is favorable, since 
the air is usually rapidly absorbed. In pneumothorax from gangrene or 
abscess of the lung the resulting pleurisy is of a septic character, and 
the prognosis is doubtful until the results of treatment are apparent. In 
pneumothorax in pulmonary tuberculosis the ultimate prognosis, as a 
rule, is unfavorable, in consequence of the frequent extensive disease of 
the lung. If the pulmonary process is sharply defined, the patient may 
recover both from the pneumothorax and from the disease of the lung. 
In the open pneumothorax following the surgical treatment of empyema 
the patient may live for years in active employment, though eventually 
likely to die from amyloid disease in consequence of the long- continued 
suppuration. 

Treatment. — The occurrence of air in the pleural cavity does not 
greatly modify the treatment of a coexisting effusion. If the latter be 
purulent, free incision and permanent drainage should be practised, as 
in simple empyema. If the exudation be serous, it may be let alone or 
may be withdrawn by aspiration, according to the amount which is 
present. "Not rarely, when pneumothorax arises in phthisis, the symptoms 
are so slight that no immediate local treatment is required. Increase of 
the fluid under such circumstances is to be met by aspiration. When 



DISEASES OF THE PLEURA. 



773 



there are such immediate distress and dyspnoea as to make it probable 
that there is high intra-thoracic pressure, a thin needle may be intro- 
duced into the portion of the pleura which is full of air, and the air be 
allowed to escape or even aspirated. If this fail to remove the distress, 
hypodermic injections of morphine become necessary. 

HYDROTHORAX. 

Definition. — The accumulation in the pleural cavity of a transuded 
fluid of non-inflammatory origin. 

Etiology. — The immediate causes of hydrothorax are obstruction to 
the outflow of subpleural venous blood and lymph and such disturbance 
of the nutrition of the walls of the blood-vessels and the lymphatics as 
occasions an increased porosity. According as the action of these causes 
is general or local, the hydrothorax is part of a general dropsy or it 
exists alone. When part of a general dropsy, the mechanical obstruction 
is the result of interference with the passage of blood through the heart 
and lungs. The hydrothorax occurring in nephritis and in the later 
stages of fibrous hepatitis is partly of mechanical origin and partly 
cachectic. It is probable, also, that the cachectic hydrothorax present 
in diseases with extreme disturbance of nutrition, as general amyloid 
degeneration and cancer, is in part of mechanical and in part of cachectic 
origin. Hydrothorax independent of general dropsy is the result of local 
pressure upon the large veins as they enter the thorax and upon the 
thoracic duct. Such pressure is occasioned by intra-thoracic tumors, 
especially of the mediastinum, and more rarely of the lungs. 

Morbid Anatomy. — The appearances vary according as fibrous adhe- 
sions between the pleura3 are present or absent and according to the 
quantity and quality of fluid. Hydrothorax is usually bilateral, but not 
infrequently one pleural cavity, especially the right, contains more fluid 
than the other. If the adhesions are distensible they become oedematous, 
and the lung is separated from the thoracic wall by a gelatinous mass, 
perhaps two inches in thickness, from which abundant serous fluid is to 
be squeezed as from a sponge. If dense adhesions are present, obliterating 
a part of the pleural cavity, encapsulated hydrothorax results. When 
an entire pleural cavity is obliterated, the hydrothorax is limited to the 
other half of the chest, although the cause may be general. Unilateral 
hydrothorax, when both pleural cavities are free from disease, usually 
depends upon the limitation of the immediate cause to the affected half 
of the chest. 

The larger the quantity of fluid, which is sometimes several quarts, 
the greater the degree of retraction of the lung and the more consider- 
able the atelectasis. The pleural surfaces are generally unaltered, at the 
most slightly opaque and of diminished lustre. The fluid is usually of 
a watery consistency, the specific gravity being below 1015, and the 
quantity of albumin less than three per cent. (See Ascites, p. 9G8.) It 



774 



DISEASES OF THE RESPIRATORY APPARATUS. 



contains occasional leukocytes, red blood- corpuscles, and desquamated 
endothelium, which may he fattily degenerated, and does not coagulate 
spontaneously unless the hydrothorax is of long duration or complicated 
with pleurisy. The fluid sometimes contains chyle, chylothorax, presuma- 
bly from obstruction of the thoracic duct or from rupture of one of its 
intra-thoracic branches. The fluid then resembles milk in color, though 
it is sometimes pink from the presence of blood. In the course of several 
hours after its removal a creamy layer forms on the surface. 

Symptoms. — Hydrothorax produces but little disturbance unless the 
quantity of fluid is large. The circulation and respiration are then dis- 
turbed, and a sense of substernal constriction, a quick, weak pulse, 
cyanosis, and dyspnoea result. These symptoms may arise when a small 
quantity of fluid only is present, especially if there is cardiac incompe- 
tency. 

Diagnosis. — The presence of free fluid in the pleural cavity is readily 
recognized from the localized dulness and absence of respiratory sounds, 
the physical signs quickly changing with the alteration of the position 
of the patient. The dropsical nature of the fluid is indicated by the 
evidence of general dropsy and the absence of fever and of pleuritic 
pain, and is confirmed by the characteristics of the aspirated fluid. In 
encapsulated or in unilateral hydrothorax, especially when of long stand- 
ing, the diagnosis may be difficult, since chronic pleurisy with liquid 
exudation often pursues a latent course and the characteristics of the 
fluid may not differ from those of the fluid of chronic hydrothorax. 

Prognosis. — Since hydrothorax is a symptom merely, the prognosis 
depends upon that of the disease which occasions it. It is, therefore, 
often favorable when due to remediable disturbances of nutrition, as 
in various ansemic conditions and in acute nephritis. When due to 
obstructive disease in the heart or lung or to intra-thoracic tumors, the 
prognosis is unfavorable, since the hydrothorax then usually represents 
the terminal stage of these affections. According to Bargebuhr, who 
has collected twenty-two cases of chylothorax, its prognosis is unfavor- 
able, seventeen of the patients having died. 

Treatment. — Immediate aspiration should be performed in an ex- 
tensive hydrothorax. If there be a tendency to reaccumulation of fluid, 
the patient should be freely purged with salines or elaterium, and hy- 
dragogue diuretics or diaphoretics should be exhibited. The disease or 
condition which produces the hydrothorax must be carefully treated. 

In chylothorax repeated tapping is undesirable, in consequence of the 
removal of a highly nutritious fluid, unless the symptoms from pressure 
are marked. 

HEMOTHORAX. 

Definition. — The presence of blood in the pleural cavity. 
Bleeding takes place into the pleural cavity in consequence of lacera- 
tion of the intra-thoracic blood-vessels from wounds of the thoracic 



DISEASES OF THE PLEURA. 



775 



wall or of the lung, or from rupture of an aneurism of the aorta or of an 
intercostal artery. Haeuiothorax occurs also when the pleura is ruptured 
in case of hemorrhage into a gangrenous or tubercular cavity. 

The resulting symptoms are those of a sudden anaemia, and vary 
according to the quantity of blood which escapes. The initial pain, of 
obvious or concealed origin, is immediately followed by vertigo and weak- 
ness and by rapid, perhaps difficult, breathing. The skin is pale, the pulse 
is quick and soft, and in severe hemorrhage the face becomes pinched, 
the skin cool and moist, and the respiration long-drawn. The blood, 
when limited in quantity, may be quickly absorbed. If considerable in 
amount, and especially if clotted, absorption may be prolonged over a 
period of weeks, the clots often becoming encapsulated at the bottom 
of the pleural cavity. When infection of the pleura is associated with 
hemothorax, as in wounds or in ruptured pulmonary cavities, pleurisy, 
usually suppurative or ichorous, results. The signs from auscultation 
and percussion are the same as in hydrothorax, and the diagnosis is 
based upon the symptoms of a rapidly progressing anaemia, the physical 
examination of the chest, and the aspiration from it of blood. 

The prognosis depends upon the cause, and may be favorable in case 
of wounds, but is necessarily fatal in ruptured aortic aneurism. In fatal 
cases death may take place quickly in consequence of the extent of the 
hemorrhage, and symptoms of collapse are then likely to be followed by 
sopor or convulsions. "When severe pleurisy accompanies the hemor- 
rhage the prognosis and treatment are essentially those of the pleurisy, 
and vary according to its etiology and nature. 

PLEURITIS. PLEURISY. 

Etiology. — Inflammation of the pleura is of great frequency, evi- 
dences of the occurrence of this disease at some time in life being found 
in the large majority of post-mortem examinations. It occurs at all 
ages, in men more often than in women, and particularly during the 
winter and early spring. A distinction is usually made between primary 
and secondary pleurisy. The former is rare, and is attributed to expo- 
sure to cold or to injury. Most cases of pleurisy, however, are secondary, 
— that is, occur in the course of various diseases with which they are 
more or less intimately connected and of which they represent a compli- 
cation, although the disturbances from the pleurisy may surpass^ those 
of the original disease. These diseases are usually of structures covered 
by the pleura, especially the lungs : hence pleurisy is frequent in pulmo- 
nary tuberculosis, pneumonia, broncho-pneumonia, pulmonary embolism, 
gangrene, and abscess. In consequence of the propinquity of the pleura 
it is inflamed frequently in the course of pericarditis, in tuberculous af- 
fections of the spine, ribs, sternum, and the subpleural lymphatic glands, 
and in cancer of the oesophagus. It occurs often when the peritoneum 
covering the diaphragm is inflamed, in general peritonitis, and in the 



776 



DISEASES OE THE RESPIRATORY APPARATUS. 



course of abscess of the liver, of appendicitis, and of nicer and cancer of 
the stomach. Pleurisy is one of the complications of acute infectious 
diseases, especially those in which the respiratory tract is sooner or 
later affected, as measles, diphtheria, influenza, typhoid fever, and septico- 
pyemia. It is of occasional occurrence in acute articular rheumatism, 
also in nephritis, gout, and syphilis. The diseases in which pleurisy is 
oftenest found are pulmonary tuberculosis, pneumonia, and broncho- 
pneumonia. 

It is the prevalent opinion that micro-organisms, either alone or in 
combination, their products, and, perhaps, chemical irritants of other 
origin are the immediate causes of the inflammation of the pleura, and 
are conveyed to this membrane by means of the blood-vessels or lym- 
phatics. The ease of their direct passage from parts covered by the 
pleura is readily understood, and their transfer by means of the circula- 
tion from remote parts, as in erysipelas, phlegmonous inflammation, sup- 
purative osteomyelitis, or gonorrhoea, is feasible. Various bacteria have 
been found in the pleuritic exudation, especially when it is purulent. 
These are the diplococcus of pneumonia, the streptococcus pyogenes, the 
staphylococcus pyogenes, and the bacillus of tuberculosis. The diplo- 
coccus of pneumonia is present particularly in the pleurisy associated 
with pneumonia, metapneumonic pleurisy, and is the variety usually found 
in the empyema of children, — according to Levy, in two-thirds of the 
cases. The streptococcus is found more often in the empyema of adults 
than in that of children. Other bacteria are more rarely seen, as Fried- 
lander 7 s bacillus, the typhoid bacillus, the colon bacillus, the gonococcus, 
the proteus vulgaris, and various saprophytic bacteria. The assertion 
often made that tuberculosis is the chief cause of pleurisy is based rather 
upon clinical and anatomical than upon bacteriological evidence. Pleu- 
risy often occurs in persons suffering from tuberculosis or in whom 
tuberculosis subsequently develops, and evidences of pleurisy are usually 
associated with those of pulmonary tuberculosis. The bacilli of tubercu- 
losis, however, are rarely found in the exudation, and then especially 
when the fluid is purulent. The assumption that nearly three-fourths of 
all cases of serous or fibri no-serous pleurisy are due to tuberculosis is best 
justified by the observations of Eichhorst, who found that guinea-pigs 
became tuberculous when inoculated with the serum from fifteen out of 
twenty-three cases, sixty-five and two-tenths per cent., of acute pleurisy 
occurring suddenly without obvious cause during health. It is further- 
more supported by the estimate that from one-third to one-half of the 
patients with simple pleurisy sooner or later become tuberculous. The 
sero-fibrinous exudation of pleurisy, as a rule, contains no bacteria, 
although in it, according to the observations of Setter, Prudden, and 
others, the diplococcus of pneumonia, the streptococcus, and the staphylo- 
coccus may be found. The purulent exudation usually contains bacteria, 
the diplococcus of pneumonia being present generally as the only micro- 



DISEASES OF THE PLEURA. 



777 



organism, — according to better, in nearly one-half of the cases, — and 
pneumonia, as a rule, is associated. The diplococcus of pneumonia may 
be present, however, in empyema when there is no lobar pneumonia. 
The streptococcus is the variety offcenest found in suppurative pleurisy 
independent of pneumonia, and the staphylococcus is only occasionally 
found. Although the typhoid bacillus has been isolated in pleurisy 
occurring in typhoid fever, usually other bacteria are present, espe- 
cially, according to Weintraud, the staphylococcus pyogenes. While 
bacteria may be the immediate cause of pleurisy, it is presumable that 
exposure to cold and injury, and the various diseases in which pleurisy is 
a complication, promote the growth of the bacteria by affording suitable 
conditions for their development. 

Morbid Anatomy. — The inflamed pleura presents various appear- 
ances, according to the stage and severity of the inflammation. They are 
circumscribed or diffused, and when limited to the vicinity of the dia- 
phragm characterize diaphragmatic pleurisy. At the outset the pleura is 
injected and without lustre, but soon it becomes thickened, opaque, and 
covered with a thin layer of fibrin, which causes a roughening of the 
surface. At this stage of the disease the alterations are designated dry 
pleurisy or fibrinous pleurisy. 

In the further progress of the inflammation the swollen pleura be- 
comes opaque from cellular infiltration, minute hemorrhages are fre- 
quent, and the subpleural fibrous tissue also is swollen from cellular 
and serous infiltration. In the pleural cavity a more or less abundant 
exudation of serum and fibrin is accumulated. This exudation varies 
in different cases in the relative proportion of serum and fibrin, and ac- 
cordingly the pleurisy is designated serous, sero-fibrinous, or fibrino- serous. 
The fibrin may appear in the thin, pale yellow fluid as flocculi, or form 
masses soaked with serum, or be present as adhesions between the 
opposite pleural surfaces. The quantity of serum may be as high as 
four quarts. It often coagulates after exposure to the air, and con- 
tains leukocytes and occasional endothelial cells. These fibrinous adhe- 
sions not infrequently enclose spaces in which the serum is retained, 
encysted pleurisy, and when the enclosed space is between the lobules the 
condition is known as interlobular pleurisy. In other cases the exudation 
is purulent, empyema. This variety is rare at the outset, except in the 
metapneumonic pleurisy of children, but frequently follows an earlier 
serous or sero-fibrinous exudation. The pus is thin or thick, yellow or 
greenish yellow, usually odorless, and the quantity of fibrin is generally 
moderate. In ichorous pleurisy the pus is thin, of a grayish color, and 
exceedingly offensive in consequence of the admission of putrefactive 
organisms from gangrene of the lung or from a fistulous communication 
with the alimentary canal, or, more rarely, from the use in treatment of 
unclean instruments. The liquid exudation at times contains more or 
less blood, the condition then being known as hemorrhagic pleurisy. This 



778 



DISEASES OF THE RESPIRATORY APPARATUS. 



variety is associated usually with tubercles or cancer of the pleura, with 
nephritis, with fibrous hepatitis, and with the hemorrhagic diatheses. 
The exudation also may contain blood if the vessels are lacerated when 
the chest is tapped, and, in rare instances, independently of the above- 
mentioned conditions. 

In pleurisy with abundant liquid exudation the lung is retracted, and 
in extreme cases is compressed into a flat mass along the spine at the 
upper and posterior portion of the chest. The compressed lung is dense, 
non- crepitant, and of a pale gray color, from diminution in the quantity 
of blood. The heart and the mediastinal tissues also are displaced to- 
wards the side of the chest which is free from disease, and the affected 
half of the diaphragm, with the subjacent spleen and stomach or liver, is 
pushed downward. 

If the exudation is absorbed, the pleura subsequently may appear 
normal or may present the characteristics of a chronic pleurisy. These are 
manifested by fibrous plates of various thickness, frequently associated 
with deformity of the lung, and there may be few or many fibrous adhe- 
sions of greater or less density, sometimes obliterating the pleural cavity 
and making it necessary in the removal of the lung to tear away the 
costal pleura. Thickening of the pleura and the formation of fibrous 
adhesions always result when the process of absorption extends over a 
long time. The delayed absorption is more likely to occur when there 
is abundant fibrin or pus, and the inflammatory product then frequently 
becomes inspissated, encapsulated, and calcified. The earthy salts often 
are deposited also in the adhesions and in the thickened pleura. In 
consequence of the shrinkage of this new-formed fibrous tissue the lung- 
is prevented from expanding, the wall of the affected half of the chest 
collapses, the intercostal spaces are obliterated, the ribs overlap, and 
lateral curvature of the spine takes place. The other half of the chest 
becomes dilated from compensatory emphysema of the contained lung. 
At times a growth of fibrous tissue extends from the pleura into the 
lung, producing a chronic interstitial pneumonia, usually associated 
with bronchiectasis and emphysema, the effects of which are described 
in the article on fibrous pneumonia. 

In suppurative pleurisy or empyema, when unrelieved by appropriate 
treatment, destruction of the pleura is likely to occur, and the pus is 
discharged either through the lung or through the thoracic wall. Per- 
foration may take place into a large bronchus, when the pus escapes 
through the mouth, or into numerous alveoli, in which case the lung 
becomes infiltrated with pus. When the costal pleura is destroyed the 
intercostal muscles are perforated, and the pus appears beneath the skin, 
usually near the lower part of the sternum, as an abscess, which often 
discharges spontaneously, sometimes in the vicinity of the navel, empyema 
necessitatis. Perforation of the pericardium, of the diaphragm, and of 
the Oesophagus also may occur. When the diaphragm is perforated the 



DISEASES OF THE PLEURA. 



779 



pus may enter the peritoneal cavity or the stomach, or extend along the 
retroperitoneal tissues and point in the groin or perineum, and may be 
discharged even into the bladder. When the fistulse have existed for a 
long time, the deformity of the lung and thorax previously mentioned 
is constant, and more or less extensive amyloid disease of the abdominal 
organs is likely to be present. 

Symptoms. — The method of onset of pleurisy varies extremely. In 
certain cases there is an initial chill, followed by a sharp knife-like pain 
in the. chest, aggravated on inspiration, and compelling the patient to 
take a short breath. In other cases there is a gradually increasing sense 
of weakness, with diminution of appetite, and shortness of breath on ex- 
ertion is the first symptom that calls attention to the existence of the 
disease. In such cases of latent pleurisy the chest may contain a large 
quantity of fluid and the patient be occupied with his customary pur- 
suits. As a rule, however, thoracic pain, stabbing or stitch- like and re- 
ferred to the region of the nipple or axilla, is present in the early stage 
of pleurisy. In diaphragmatic pleurisy the pain follows the line of the 
costal insertions of the diaphragm, and sometimes extends into the 
shoulder and neck ; and in this variety, according to De Mussy, the pain 
is most severe one or two finger-breadths from the median line and on 
a level with the tenth rib. There is a frequent dry cough, usually sup- 
pressed through fear of increasing the pain, and hiccough is frequent 
in diaphragmatic pleurisy, although the presence of this symptom in 
pleurisy is not to be regarded as indicating an especial localization of the 
inflammation in the pleural covering of the diaphragm. The temperature 
is elevated two or three degrees, and the frequency of the respiration and 
pulse is increased. In dry pleurisy there may be little or no fever ; in 
serous pleurisy it is moderate in degree, but in suppurative pleurisy the 
temperature is frequently as high as 103° or 104° F., and wide varia- 
tions between the morning and the evening temperature occur. Intercur- 
rent chills are also present. Sweating is frequent and often profuse in 
suppurative' pleurisy. In the course of a week or two as the exudation 
increases in quantity the stitch-like pain disappears in consequence of 
the separation of the inflamed pleural surfaces, and is replaced by a 
sense of distention and weight at the lower part of the thorax, but 
the dyspnoea becomes more considerable. The greater the quantity of 
the liquid exudation the more likely is cyanosis to be present. There 
is also a sense of substernal constriction, especially when the heart is 
displaced, and there is pain in the lower part of the chest from the 
pressure of the exudation. 

The patient, if confined to the bed, prefers to sit upright, or with 
the back supported ; if in the lateral position, he usually lies upon the 
diseased side. In diaphragmatic pleurisy the body is bent forward, 
the hands are frequently applied to the sides to restrain the movements 
of the chest, and the expression is one of great suffering. 



780 



DISEASES OE THE RESPIRATORY APPARATUS. 



Physical Examination. — On inspection, when there is considerable 
serons exudation, distention of the thorax is perceptible. The intercostal 
spaces are prominent, and absent or diminished motion of the distended 
chest is apparent. The apex-beat of the heart may be outside of the left 
nipple in extensive pleurisy of the right chest, and may be invisible or be 
found at the right of the sternum in pleurisy of the left half of the chest. 
On palpation there is recognized by the hand a rubbing sensation in dry 
pleurisy and impaired mobility of the chest in the sero-fibrinous variety. 
Especially important as indicative of liquid exudation is the absence of 
vocal fremitus. In case of displacement of the spleen or the liver, these 
organs are to be felt through the abdominal wall. Percussion gives evi- 
dence of the presence of the exudation when more than six ounces are 
accumulated, since extreme dulness or flatness and a sense of resistance 
to the percussing finger are caused. The limits of the upper border of flat- 
ness vary in accordance with the quantity of fluid present. In left-sided 
pleurisy the dulness is to be recognized first in Traube's semilunar space, 
where the stomach is overlain by the complementary space of the pleural 
cavity. When the quantity of fluid is moderate, not extending above 
the inferior angle of the scapula, the upper border of dulness is usually 
transverse. With considerable degrees of exudation the line of dulness 
forms a curve the highest point of which is in the axilla. Damoiseau 
asserted that the upper border of dulness formed a parabola with the 
highest point in the axillary line. Ellis also found the highest point of 
dulness in the axillary line, from which the upper border of dulness in- 
clined slightly downward towards the sternum. He discovered that the 
curved line of dulness between the spine and the axilla was shaped like 
the letter S. This observation was corroborated by Garland by means of 
experiments on animals. When the chest is filled with fluid the letter 8 
outline disappears and the curve rapidly rises to its highest point at the 
top of the shoulder, resonance being found only at the upper part of the 
chest between the scapula and the spine and beneath the clavicle, where 
it has a tympanitic, and at times on strong percussion a cracked-pot, char- 
acter, best to be heard by listening at the open mouth of the patient. The 
tympanitic resonance is at times higher in pitch when the mouth is open 
than when shut. The outline of the displaced stomach or liver is to be 
determined also by percussion. On auscultation in the vicinity of the 
seat of pain in the early stage of pleurisy there is to be heard on inspira- 
tion and expiration a continuous sound, often compared to the creaking 
of leather, the pleuritic friction- sound, due to the rubbing of the apposed 
pleurse roughened from adherent fibrin. As the liquid exudation accu- 
mulates this sound disappears, and the respiratory and vocal sounds are 
feeble or absent. When the liquid exudation is excessive and produces 
compression of the lung the breathing is bronchial, being loudest at the 
upper part of the chest, and especially in the back, and may be apparent 
as a distant sound in the region of dulness, but in children may be so 



DISEASES OF THE PLEUBA. 



781 



loud as to suggest consolidation of the lung. The voice- sound also is 
feebly transmitted, except in the region of bronchial breathing, in which 
place there is bronchophony, and not infrequently in extensive serous 
exudation the transmitted voice-sound has a peculiar nasal character 
compared to the bleating of a goat, and designated segophony. Accord- 
ing to Baccelli, the whispered voice is transmitted through a serous but 
not through a purulent exudation. 

In the course of two or three weeks after the onset of fibrinous 
pleurisy, or when there is but little serous exudation, the fever sub- 
sides, the exudation is absorbed, the friction -sound is again to be heard, 
though eventually disappearing, and recovery takes place by resolution. 
If the fever persists into the third or the fourth week and the physical 
signs of exudation are present, the disease, if untreated, may become 
chronic, lasting for months, in which case its tuberculous nature is es- 
pecially to be suspected. The serous fluid then may be gradually ab- 
sorbed, and a permanent thickening of the pleura with possible incom- 
plete expansion of the lung and deformity of the chest be the result. 
If the liquid exudation is extreme, sudden death may occur from pul- 
monary embolism, from oedema of the unaffected lung, from weakened 
action of the heart in consequence of its displacement, or, according to 
Bartels, in left-sided pleurisy from obstruction of the passage of blood 
through the inferior vena cava in consequence of its compression by 
the exudation. 

Suppurative pleurisy occurs at all ages, and when metapneumonic is 
usually limited to the region of the affected lobe, not becoming manifest 
until at least a week after the pneumonia has begun. The constitutional 
disturbances in empyema are apt to be considerable, but the affection of 
respiration is often slight. There is frequently a marked leukocytosis, 
and peptonuria has been observed. When the wall of the chest is per- 
forated and the pus appears beneath the skin, so-called empyema neces- 
sitatis, oedema of the skin over the lower portion of the chest usually 
precedes the appearance of the pus, which is indicated by the appear- 
ance of one or more fluctuating subcutaneous tumors, generally in the 
vicinity of the fifth rib near the sternum. 

When the empyema is in the left half of the chest, and in rare 
instances in empyema of the right half, the pulsations of the heart are 
transmitted by the exudation, and are to be seen or felt as a more or less 
forcible heaving of the chest- wall, oftenest in the second and third inter- 
costal spaces, and synchronous with the beat of the heart, intrapleural 
pulsating empyema. The pulsations may be visible also in the superficial 
abscesses occurring in empyema necessitatis, and have been observed not 
only in the front of the chest, but also in the back and in the left lumbar 
region. Osier and Wilson have recently called especial attention to the 
occurrence of pulsating pleurisy, and in the collection of sixty-six cases, 
mostly in males, made by Wilson, the pleurisy was on the left side in 



782 



DISEASES OF THE RESPIRATORY APPARATUS. 



sixty-one cases, and the exudation, almost invariably purulent, was intra- 
pleural in twenty-eight instances, and was manifested as an empyema 
necessitatis in thirty-seven cases. Important in the production of pul- 
sating pleurisy are a weakness of the intercostal muscles or a perforation 
of the parietal pleura and strong cardiac action. Toulmin has shown 
that an increased intra-pleural pressure is not essential, since the aspira- 
tion of several ounces of fluid was not followed by cessation of the 
pulsation. 

Pneumothorax is a frequent complication of empyema. (See Pneumo- 
thorax, page 770.) Perforation into the bronchi, so often recovered from, 
is sometimes a cause of immediate death by the flooding of the lungs 
with pus. 

Diagnosis. — The suspicion of a pleurisy is excited by the occurrence 
of thoracic pain, a short dry cough, rapid respiration, and elevated tem- 
perature. The diagnosis is based essentially upon the physical signs. 
Since many of the symptoms, and such of the signs as dulness on per- 
cussion, bronchial breathing, and bronchophony, at times occur in both 
pleurisy and pneumonia, these diseases are not infrequently confounded. 
In typical cases with abundant exudation there is but little difficulty in 
diagnosis, since the onset of pneumonia is sudden and usually announced 
by a chill, which is immediately followed by a marked elevation of tem- 
perature, pursuing a relatively typical course. There is a characteristic 
rusty sputum, and the chlorides of the urine are markedly diminished. 
Abundant, fine, moist, subcrepitant rales are followed by bronchial 
breathing and bronchophony, to be replaced by the return of the rales. 
In pleurisy, on the contrary, the onset is neither so sudden nor so 
violent, the fever is lower, the discomfort is less, and rusty sputa are 
absent. At the outset a continuous rub is to be heard, instead of sub- 
crepitant rales at the end of inspiration. Where dulness is present 
the chest is distended, the vocal and respiratory sounds are distant or 
absent, not bronchial, the vocal fremitus is diminished, and the physi- 
cal signs are not limited to the lobar structure of the lung. When the 
bronchi, however, are obstructed in pneumonia, bronchial breathing is 
absent and the sounds of the voice are not transmitted, and in moderate 
pleuritic exudation, especially when circumscribed between the lobes, 
there may be no characteristic dulness. Localized dulness and feeble 
respiratory and vocal sounds may be produced also by pleural thicken- 
ing and by thoracic tumors. The absence of fever, the slow progress of 
the disease, and the freedom from symptoms of pressure upon the larger 
bronchi and blood-vessels may aid in the diagnosis of the tumor, but 
are of little avail in differentiating pleural thickening from pleuritic 
exudation. In pulsating pleurisy the presence of aneurism is not in- 
frequently suggested, and, although in general the absence of murmurs 
and the seat of the dulness and pulsation are sufficient in diagnosis, the 
possibility of doubt is not always thus to be excluded. The pulsating 



DISEASES OF THE PLEURA. 



783 



tumor of empyema necessitatis also may be so seated as to suggest an- 
eurism, but its tension is influenced by respiration, and pressure may 
empty the sac. 

Sooner or later an exploratory puncture of the chest is likely to be 
demanded for therapeutic, if not for diagnostic, purposes. It is practi- 
cally without risk if the ordinary precautions against septic infection 
are employed, even when several punctures are made, which are some- 
times necessary, especially when the fluid is encapsulated. The with- 
drawal of fluid from the pleural cavity at once eliminates pneumonia, 
pleuritic thickening, and pleural tumors, unless combined with liquid 
exudation. If the fluid is free from blood, aneurism is excluded. The 
inflammatory instead of the dropsical nature of the serous fluid is 
indicated by its specific gravity, upward of 1015, its high percentage 
of albumin, and its frequent spontaneous coagulation. A bloody fluid, 
in the absence of the signs of aneurism, is suggestive of tuberculosis 
or cancer of the pleurae, but may be found in pleurisy independently 
of these affections, as has been stated in the section on morbid anatomy. 
The presence of a thick pus is suggestive of a metapneumonic pleurisy, 
and the recognition of the diplococcus of pneumonia would confirm 
this view. The pus is thin in empyema from streptococcus infection, 
and both thin and offensive in putrid empyema. Circumscribed dulness 
and protrusion of the intercostal spaces, associated with an irregular 
range of temperature, due to the presence of pus in the subpleural 
tissue, peripleuritis, sometimes occur apparently spontaneously, and are 
with difficulty to be differentiated from an encapsulated empyema. 
Even when empyema is manifested by the exploratory puncture it may 
be necessary to know whether the exudation is above or below the dia- 
phragm. Empyema or pyopneumothorax is to be diffentiated from sub- 
phrenic abscess or subphrenic pyopneumothorax first by the early symp- 
toms, which in empyema relate to respiration and not to digestion. The 
signs of displacement of the lung, and perhaps of displacement of the 
heart, are present in suppurating pleurisy to a much greater extent 
than in subphrenic peritonitis. Especially important, according to 
Litten, in the differential diagnosis is the relation of the phrenic phe- 
nomenon to dulness. When the broad, moving shadow indicative of 
the entrance of the lower border of the lung into the complementary 
space is seen above the level of dulness, the cause of the latter is below 
the diaphragm. The upward displacement of the diaphragm by a large 
abscess of the liver produces the effect upon the lung of pleuritic exu- 
dation, but the outline of dulness is convex upward. Circumscribed 
pleurisy in the left half of the chest may with difficulty be discrimi- 
nated from pericarditis, in the fibrinous stage of which a continuous 
friction-sound is to be heard ; but its persistence when the breath is held 
excludes its pleural origin. When the pleuritic exudation is liquid and 
abundant the heart is dislocated, but the dyspnoea and discomfort are 



784 



DISEASES OF THE RESPIRATORY APPARATUS. 



not so great as would be the case in pericarditic exudation with an equally 
extensive area of dulness. 

Prognosis. — The prognosis of pleurisy varies mainly in accordance 
with the anatomical variety, which is largely dependent upon the imme- 
diate cause. In general it has been estimated that death occurs from 
pleurisy alone in about five per. cent, of the cases. Dry or fibrinous 
pleurisy usually terminates favorably in the course of a few weeks. In 
serous or sero-fibrinous pleurisy absorption of the fluid may take place 
and recovery be established in the course of a month, but, as previously 
stated, death may occur suddenly when the quantity of the liquid exuda- 
tion is excessive. This variety, however, not infrequently pursues a 
chronic course, perhaps manifested by frequent recurrences, and extends 
over a period of months. In such cases the prognosis is to be guarded, 
especially since nearly one-half of the sufferers sooner or later are afflicted 
with tuberculosis. Pulmonary phthisis was present in one-third of Bow- 
ditch's cases observed in the course of thirty years. In hemorrhagic 
pleurisy the prognosis is grave, though not necessarily hopeless, from 
the frequency with which extensive tuberculosis or malignant disease of 
the pleura is associated. Suppurative pleurisy has a doubtful prognosis. 
Frequent recoveries occurred before the days of its surgical treatment 
from the spontaneous evacuation of pus either into the lungs or through 
the walls of the chest in empyema necessitatis, but the mortality of em- 
pyema varies largely with reference to the cause and to the condition of 
the wall of the chest at the time of treatment. Metapneumonic empyema, 
the variety associated with pneumonia and due to the diplococcus of 
this disease, has a mortality ranging between two per cent, and ten per 
cent. In children it is frequently recovered from after a single aspiration 
of the pus. Empyema due to staphylococcus infection also may be re- 
covered from after simple aspiration. If the pus contains streptococci 
the prognosis is more serious, since septic infection of the body is likely 
to exist, but, on the whole, is favorable, provided that its nature is early 
discovered, that its surgical treatment soon follows, and that there are no 
grave complications. The prognosis of ichorous pleurisy is also serious, 
but not necessarily fatal, if early surgical treatment is instituted. Em- 
pyema of tubercular origin is usually sooner or later fatal, either from 
amyloid disease following the long-continued drainage from the chest or 
from tuberculosis elsewhere. When there is extensive deformity of the 
chest in consequence of chronic pleurisy and inability of the lung to 
expand from fibrous pneumonia, the prognosis depends essentially upon 
the condition of the heart, the right side of which becomes dilated and 
hypertrophied. In the course of years insufficiency of the heart is likely 
to arise, and the prognosis becomes that of an incompetent heart. 

Treatment. — In acute sthenic pleurisy with fibrinous exudation im- 
mediate relief to the pain and often distinct modification of the disease 
can be obtained by local blood-letting, by means either of leeches or of 



DISEASES OF THE PLEURA. 



785 



wet cups, to the extent of from three to seven ounces, according to the 
strength of the patient. Dry cups should never be used, as in thin -walled 
chests their irritating influence may extend through to the pleura. If 
the pain be not relieved, strapping the affected half of the chest in the 
manner practised for fracture of the ribs will often, by arresting respira- 
tory movement, afford great comfort to the patient, and lessen the irri- 
tating influences upon the inflamed area of excessive movement. In some 
cases an ice-bag is agreeable to the patient, and may be employed. More 
usually warm moist applications, as poultices, are preferred. Internally 
calomel should be given in small doses at regular intervals, partly for the 
purpose of thoroughly emptying the alimentary canal, but largely for 
the effect which it has in lessening the amount of fibrinous exudation and 
also the inflammatory changes in serous membranes. Potassium iodide 
is in no way capahle of replacing it, and even in chronic pleurisy with 
serous exudation the power of the iodide is doubtful. 

When serous effusion has taken place, mustard plasters and simi- 
lar rubefacients are of no value, and it is doubtful whether the local 
application of iodine, though much practised, has any effect. If the 
iodine be used it should be in the form of the saturated solution in oil, 
which should be well rubbed into the side twice a day. There can be 
no doubt as to the great value of large blisters during the forming stage 
of serous effusion. If the effusion does not increase, they should be re- 
peated frequently at short intervals. The so-called " dry" treatment has 
for its object the lessening of the fluids of the body by cutting off the 
supply of water : its effectiveness is, however, doubtful. The liquid 
allowed in the twenty -four hours is reduced to eight or ten fluidounces, 
meat, dry bread, eggs, and other foods containing very little water being 
selected according to the needs of the case. During the period of diet- 
ing salines are freely to be given, once, twice, or three times in the forty- 
eight hours, according to the strength of the patient, — from one to two 
ounces of Rochelle salt, or from half an ounce to an ounce of Epsom salt, 
in a little water. The old-fashioned diuretic pill, one grain each of 
calomel, digitalis, and squill, is a very effective diuretic combination 
which may be employed— one every six to every eight hours— during the 
dry treatment. When the effusion rapidly fills almost the whole chest, 
or when in spite of the application of blisters it continues to increase, 
aspiration should be practised. The operation properly performed is 
without clanger in a suitable case. 

The rule formulated forty years ago by Henry I. Bowditch, of Boston, 
that "in any case of even moderate effusion lasting more than a few 
weeks, and in which there should seem to be a tendency to resist ordinary 
mode of treatment,- ' aspiration should be practised, is correct; and when 
the pleural cavity is found full of fluid there should be no waiting to test 
the possibility of getting rid of the fluid by medicinal treatment. In 
the performance of paracentesis thoracis the antisepsis should be abso- 

50 



786 



DISEASES OF THE RESPIRATORY APPARATUS. 



lute. The skin should be thoroughly washed with soap and water, then 
treated for ten to fifteen minutes with a solution of corrosive sublimate 
1 to 500, and, after the use of ice and salt for the purpose of pro- 
ducing local anaesthesia, should again be well washed with eighty per 
cent, alcohol immediately before the needle is introduced. The point of 
election is in the seventh interspace, below the centre of the axilla, or 
in the eighth interspace, at the outer angle of the scapula. The inter- 
spaces may be widened by raising the point of the elbow outward and 
upward. The needle should be thrust through close to the upper margin 
of the rib, so as to avoid the intercostal artery. The fluid should be 
taken away not too rapidly, from one to four pints, according to the 
amount of the exudate. Any symptoms of syncope should be the signal 
for the withdrawal of the aspirator, since sudden death is said to have 
occurred during pleural aspiration. 

The condition of great distress, with albuminous expectoration and 
dyspnoea, spoken of by some writers, we have never seen. It is not 
rare for severe coughing to come on after some of the fluid has been taken 
out : if it be excessive, the aspirating needle should be withdrawn ; and 
if the cough still continue, a hypodermic injection of morphine should 
be given. 

After the aspiration the treatment directed for the removal of serous 
effusion in the preceding paragraphs may be often advantageously prac- 
tised for the purpose of delaying the reaccumulation of fluid. 

The treatment of empyema is that of abscess, but in children a single 
aspiration sometimes cures an empyema ; if it fail, and in adults what- 
ever the symptoms may be, however desperate the patient's condition 
may appear, the pleura should be freely opened and thoroughly drained. 
If the empyema be an old one, or if the discharge be in any degree fetid, 
the whole cavity should be well washed out with warm sterilized water. 
Resection of the rib and insertion of a drainage-tube are often necessary. 

The general treatment should be supporting and symptomatic ; ad- 
vantage is often found in allowing the patients, as they grow stronger, to 
use several times a day an apparatus made by so uniting two large Wolfe 
bottles, or two half-gallon jars with rubber corks doubly perforated, that 
the patient can blow backward and forward from one to the other a half- 
gallon of water. The expansion of the lungs, which this apparatus is 
supposed to aid, may often be assisted with advantage by the cautious 
use of the pneumatic cabinet or of pulmonic gymnastics, and after con- 
valescence by living at high elevations. 

Chronic pleurisy is to be treated by aspiration when the fluid is in 
excess, by repeated blistering followed by the local use of a saturated 
solution of iodine in oil, and by building up the general condition of the 
patient. In many cases deep breathing, the pneumatic cabinet, and other 
forms of respiratory gymnastics are of service. When it is possible, in 
an obstinate case the patient should live in a dry, equable climate. 



DISEASES OF THE MEDIASTINUM. 



787 



TUMORS OF THE PLEURA. 

Primary and secondary pleural tumors are to be found. The former 
are fibroma, lipoma, osteoma, sarcoma, and endothelioma, and arise from 
the pleura or the subpleural tissue. The secondary tumors are lym- 
phoma, sarcoma, and cancer, and invade the pleura from neighboring 
or remote parts by means of the blood-vessels or lymphatics. In such 
instances the primary seat of the disease is to be found in the medias- 
tinal lymph-glands, the ribs, the mammary gland, the oesophagus, the 
stomach, or elsewhere. Those of especial clinical interest are the 
malignant tumors, among which are lymphoma, sarcoma, endothelioma, 
and cancer. 

The morbid growth is manifested as a diffuse thickening of the 
pleura, or circumscribed nodules, often multiple and sometimes minute, 
are present. The new formation is hard or soft, often very vascular, and 
is usually present on the parietal and visceral layers. Hydrothorax or 
pleurisy is frequently associated, and considerable quantities of liquid 
may be the result. As a rule, the symptoms are those of a chronic 
progressive pleurisy associated with emaciation, pallor, and debility. 
Occasional stitches and slight disturbance of respiration, especially on 
exertion, may exist for some time before the evidence of fluid is present. 
In other cases the growth of the tumors is rapid, and is associated with 
fever and abundant exudation without especial disturbance of nutrition. 
The diagnosis is based ordinarily upon the presence of symptoms and 
signs suggestive of a pleurisy or hydrothorax, and is substantiated by 
the withdrawal from the chest of a bloody fluid in which, at times, the 
structural characteristics of a malignant new formation are to be found. 
The prognosis of malignant growths of the pleura is necessarily fatal, 
death occurring usually within a few months after dyspnoea becomes 
prominent or aspiration necessary. The treatment consists in the relief 
of symptoms as they arise, especially in the frequent withdrawal of fluid 
when it is a cause of dyspnoea, and in the relief of pain by opiates. 

DISEASES OF THE MEDIASTINUM. 

MEDIASTINITIS. 

Acute and chronic inflammation of the fibrous tissue of the mediasti- 
num occur : both are due to extension of inflammatory processes from 
neighboring parts. Acute mediastinitis follows injury or deep-seated 
inflammation of the fibrous tissue of the neck, whether proceeding 
from the vicinity of the submaxillary glands or originating as a retro- 
pharyngeal process. Acute mediastinitis at times is caused by infection 
of a wound in tracheotomy or in cut-throat. It is likely to result from 
perforation or rupture of the oesophagus, or from abscesses of the medias 
final lymph-glands, and to be continued from a pleurisy or a pericarditis. 



788 



DISEASES OF THE RESPIRATORY APPARATUS. 



Chronic mediastinitis may be the outcome of an acute mediastinitis, 
but is especially likely to accompany chronic inflammatory processes 
of the thymus or of the mediastinal lymph -glands or of the spine and 
the sternum. Especial attention has been directed of late years to the 
concurrence of mediastinitis and pericarditis, a condition designated 
indurative mediastinitis or mediastino-pericarditis. 

Acute mediastinitis occurs either as a phlegmonous inflammation 
characterized by a gelatinous infiltration of the fibrous tissues with serum 
and cells, or as a substernal or pericesophageal abscess. In indurative 
or chronic fibrous mediastinitis the fibrous tissue of the mediastinum is 
thickened and dense, and fibrous obliteration of the pericardial cavity is 
frequently associated. 

The symptoms of acute mediastinitis vary in accordance with the seat 
of the inflammation in the anterior or in the posterior mediastinum, and 
are dependent also upon the quantity of the exudation. Chills and fever, 
sweats and prostration, delirium or stupor, and a rapid and weak pulse, 
which are present to a greater or less extent, are attributable to the pri- 
mary, inflammation. Evidence of the localization of the inflammation in 
the mediastinum is afforded by substernal pain, especially near the ensi- 
form cartilage, and sometimes very severe, and dyspnoea or difficulty in 
swallowing when the abscess is of sufficient size to produce mechanical 
interference with breathing and deglutition. The presence of a large 
abscess in the anterior mediastinum not only causes dyspnoea and weaken- 
ing of the action of the heart, but also may be manifested above or at the 
side of the sternum by an elastic, perhaps fluctuating, swelling, which 
may transmit pulsation from the neighboring arteries. The pulsation, 
however, is not expansile, there is no double murmur, and the heart- 
sounds are feebly transmitted. The pus may be discharged into the 
oesophagus or into the trachea. It may enter the pleural cavity or be 
discharged externally through an intercostal space in the vicinity of the 
sternum, or it may escape through the abdominal wall. Acute mediasti- 
nitis is a severe affection, and not infrequently proves the cause of death 
soon after its occurrence. 

Chronic mediastinitis is sometimes manifested by an abscess, in which 
case its origin from a tubercular process is probable. The pus may be- 
come inspissated, or, as in the case mentioned by Da Costa, be discharged 
by the mouth after a year of symptoms resembling those due to aortic 
aneurism. In chronic fibrous mediastinitis associated with an obliterated 
pericardium and hypertrophy and dilatation of the heart the symptoms 
are shortness of breath, cyanosis, and dropsy, not infrequently associated 
with increasing weakness of the pulse on inspiration, — the paradoxical 
pulse of Kussmaul. 

Treatment.— A mediastinal abscess should be aspirated, great care 
being taken to prevent the admission of air during or after the opera- 
tion. 



DISEASES OF THE MEDIASTINUM. 



789 



TUMORS OF THE MEDIASTINUM. 

Tumors of the mediastinum are of occasional occurrence, and proceed 
from the thymus, the mediastinal lymph-glands, and the fibrous tissue 
or the thyroid gland, especially a supernumerary or an aberrant thyroid. 
The primary tumors are lymphoma of the thymus or of the lymph- 
glands, sarcoma of the fibrous tissue, and, rarest of all, dermoid cyst. 
The secondary tumors proceed from the lymph-glands, which are often 
cancerous and sometimes sarcomatous in consequence of malignant dis- 
ease elsewhere in the body. The mediastinal tumor oftenest found is 
lymphoma, usually multiple, and occurring independently as malignant 
lymphoma or in connection with similar tumors of the lymph-glands 
elsewhere in the body in leukaemia and in pseudo-leukaemia. 

Symptoms. — The disturbances caused by tumors of the mediastinum 
are due to their pressure upon adjacent parts. One of the earliest as well 
as one of the most persistent symptoms is dyspnoea, which may result 
from pressure upon the trachea or a bronchus or upon the lung itself, 
and may be caused also by compression of the pneumogastric nerve, in 
which case paroxysms of dyspnoea of an asthmatic character result. The 
dyspnoea often is added to by fluid in the pleural cavity. Orthopnoea 
eventually may occur and persist until death takes place. Usually, next 
in sequence are the manifestations of pressure upon the veins entering 
the thorax, especially of the superior vena cava or of an innominate 
vein. If the superior vena cava is obstructed, there is venous conges- 
tion of the head, arms, and upper half of the body, manifested by head- 
ache, vertigo, ringing in the ears, and cyanosis and oedema of the skin. 
The obstruction may be so considerable that there is conspicuous dilata- 
tion of the anastomoses between the cutaneous veins of the chest and 
of the abdomen. If but one innominate vein is compressed, the cyanosis 
and oedema are limited to the corresponding half of the face, neck, chest, 
and arm. If the tumor is so situated as to press upon the inferior vena 
cava, there is oedema of the lower half of the body. The effect of press- 
ure upon the arteries proceeding to the arm may be manifested by differ- 
ences in the strength of the radial pulses. Pressure upon the oesophagus 
causes difficulty of swallowing. This symptom also results from pressure 
on the pneumogastric nerve, and, in addition, the frequency of the pulse 
is diminished if the nerve is irritated, and quickened and irregular when 
the nerve is paralyzed. Pressure on the phrenic nerve causes hiccough, 
and quickened respiration also, from interference with the movement of 
the diaphragm. There are hoarseness or aphonia from paralysis of the 
vocal cords if the laryngeal nerves are compressed, and irregularity of 
the pupils from pressure upon the sympathetic nerves. Numbness or 
pain in the chest and arms at times occurs, in consequence of pressure 
upon the nerves proceeding to these parts. There is a frequent dry 
cough, which is sometimes stridulous, and blood is occasionally mixed 



790 



DISEASES OF THE RESPIRATORY APPARATUS. 



with the sputum. There may be but little disturbance of nutrition, or 
the appetite may fail and emaciation rapidly take place. The patient is 
often distressed from loss of sleep. 

The tumor may be so large as to cause circumscribed distention of 
the chest and impairment of its motion, and at times is to be seen or felt 
in the sternal notch, in which case it may transmit the pulsations of the 
larger arteries. In malignant lymphoma enlargement of the supraclavic- 
ular or axillary glands on one or both sides may be felt. In rare instances 
the tumor may perforate the wall of the chest and appear as a subcutane- 
ous nodule. The heart is at times displaced downward and outward. On 
percussion there is an irregular area of dulness, usually in the region of 
the upper half of the sternum. On auscultation murmurs may be heard 
from pressure upon the large blood-vessels, and in the region of dulness 
the voice-sounds and the respiratory murmur are enfeebled. If a large 
bronchus is compressed, a localized musical murmur is likely to be heard, 
the respiratory sounds being feeble and the expiration prolonged in that 
part of the lung which is reached by the obstructed bronchus. If the 
tumor overlies the heart, the valvular sounds are somewhat indistinct. 

Diagnosis. — The symptoms and signs generally are those indicative 
of an intra-thoracic tumor, and are often suggestive of an aneurism 
of the aorta. An expansile pulsation, however, and a characteristic 
double murmur are lacking. The malignant nature of the tumor is 
directly to be inferred by the presence of enlarged glands in the neck or 
axilla. Pleurisy is to be excluded by the absence of fever, the irregular 
area of dulness, and the usual limitation of the symptoms of pressure to 
the upper part of the chest. The use of the exploring needle may be 
necessary in the differential diagnosis of pleuritic exudation and medias- 
tinal abscess. When hydrothorax or pleurisy complicates a mediastinal 
tumor, the aspirated fluid may be bloody ; its removal is not followed by 
relief of the symptoms of pressure, and the fluid quickly returns. The 
dulness due to pericardial effusion may suggest that from a mediastinal 
tumor, but pericarditis is preceded by inflammatory symptoms, and the 
apex-beat is to be recognized between the sternum and the outer border 
of dulness, and not at this point, as in tumor. 

Prognosis. — Mediastinal tumors, except in case of the rare dermoid 
cyst or hydatid, are beyond the reach of the surgeon, and the prognosis, 
therefore, is in general to be regarded as hopeless. Death usually occurs 
in the course of weeks or a few months after the onset of the symptoms, 
and is due to exhaustion or gradual asphyxia, the intelligence of the 
patient often being preserved up to the time of death. 

Treatment. — Mediastinal tumors, so far as their therapeusis is con- 
cerned, are chiefly surgical disorders, but a trial should be made of 
arsenic in malignant lymphomata, and Lugol's solution should be ex- 
hibited when the tumors are of thyroid origin. Considerable accumu- 
lations of fluid in the pleural cavity are to be removed by aspiration. 



SECTION Y. 



DISEASES OF THE DIGESTIVE APPARATUS AND 
OF THE PERITONEUM. 



OHAPTEE I. 

DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, PHARYNX, 

AND CESOPHAGUS. 

STOMATITIS. 

Definition. — Inflammation of the raucous membrane of the mouth. 

The mucous membrane lining the mouth is frequently the seat of in- 
flammation, which is often diffused, though sometimes circumscribed to 
the tongue, gums, palate, or cheeks. 

Etiology. — Of first importance in the causation of stomatitis are 
local irritants, among which are included excessively hot or acrid arti- 
cles of food, tobacco, chewed or smoked, caustics, the eruption of teeth 
in infants, carious teeth or ill-fitting artificial teeth, the putrefactive 
changes in particles of food retained in consequence of insufficient care 
of the teeth, the direct inoculation of pathogenic bacteria or fungi, or 
their transfer, as in erysipelas, from the neighboring surface of the body 
through the lymphatics. Stomatitis also results from the extension of 
inflammatory processes into the mouth from the nose or the pharynx. 
It takes place in the course of infectious diseases, especially in measles, 
scarlet fever, small-pox, and syphilis, also in scurvy, and is a not infre- 
quent complication of diphtheria. In this connection the repeated occur- 
rence of stomatitis as an epidemic may be mentioned. Certain poisons, 
notably mercury, arsenic, bismuth, lead, and potassium iodide, act, after 
their absorption, as causes of stomatitis. 

Varieties. — The varieties of stomatitis usually differentiated are the 
catarrhal, aphthous, ulcerative, gangrenous, and parasitic. In catarrhal 
stomatitis the mucous membrane, especially of the gums and cheeks, is 
reddened and swollen, and there is an increased secretion of mucus and 
saliva. Blisters, usually small, often form, break, and leave behind a 
raw surface. The catarrhal variety of stomatitis may become purulent 
in severe cases, as from gonococcal infection. 

Aphthous stomatitis is a variety of catarrhal stomatitis in which some- 
what painful, small, round, gray spots with a red margin appear at the 

791 



792 



DISEASES OF THE DIGESTIVE APPARATUS. 



edge of the tongue or upon the cheek. These spots, popularly spoken of 
as canker, may become confluent, and are due apparently to a thickening 
of papillae from cellular or fibrinous exudation. 

In parasitic stomatitis, or thrush, the catarrhal stomatitis is accompanied 
with soft, curd-like, slightly elevated, opaque white patches, to be scraped 
from the surface, which is slightly reddened. These patches are composed 
of the mycelial threads and buds of a fungus, the oidium albicans, which 
grows between the epidermic layers of the surface. Thrush occurs par- 
ticularly among feeble infants improperly fed, especially from unclean 
bottles, but is to be found also in adults enfeebled by disease or want. 
The fungous patches may extend from the gums and cheeks to the pharynx 
and the oesophagus. 

Ulcerative stomatitis represents a more severe variety than those pre- 
ceding, and is especially found among children crowded together under 
unsatisfactory hygienic surroundings ; it also occurs in mercurial poi- 
soning, and as a result of scurvy, in which case the exudation is hem- 
orrhagic as well as purulent. The swelling of the gums is more conspic- 
uous than in simple stomatitis, and ulcers are to be seen especially in 
the vicinity of the teeth. The inflammation may extend to the alveoli 
and to the periosteum, causing loss of teeth and necrosis of bone. 

Gangrenous stomatitis is a rare affection, probably of bacterial origin, 
occurring especially among children, although sometimes found in adults. 
The disease is considered non-contagious, although in repeated instances 
numerous persons, especially in asylums, have been simultaneously af- 
fected. It is likely to occur among persons reduced by hardship or by 
severe diseases, although it sometimes is found in those otherwise in 
good health. This variety of stomatitis is also known as noma or can- 
crum oris, and is essentially a rapidly spreading moist gangrene. It 
usually begins at the corner of the mouth, where a black discolora- 
tion of the mucous membrane is surrounded by an inflammatory swell- 
ing. As the central necrosis is extended the peripheral inflammation 
advances. 

Symptoms. — In catarrhal stomatitis the complaint is of a sore mouth, 
disagreeable taste, offensive odor of the breath, and unwillingness to take 
food, partly from the discomfort of swallowing, partly from a lack of appe- 
tite. The unwillingness to swallow explains the frequency of drooling, 
and the consequent excoriation of the skin from maceration of the epi- 
dermis. There is little or no elevation of temperature. In aphthous 
stomatitis the inflamed spots are discomforting, but not especially pain- 
ful. Salivation and difficulty in swallowing are inconsiderable. In 
thrush the local disturbances are still less, the mucous membrane being 
only slightly sensitive when the fungous patches are detached, but the 
possibility of oesophageal obstruction from the growth of the fungus in 
the gullet is to be remembered. These varieties of stomatitis are rela- 
tively mild, of short duration, and easily relieved by treatment. 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 793 

In ulcerative stomatitis similar symptoms occur, but are severe. The 
flow of saliva is more profuse, pus and blood are present in the secretions 
from the mouth, and the odor of the breath is extremely offensive. The 
neighboring lymph-glands are swollen' and tender, there is distinct febrile 
disturbance, and the disease is likely to have a protracted course. 

In gangrenous stomatitis the swelling of the lymph-glands and the 
fever are even more extreme than in ulcerative stomatitis, and hemor- 
rhages are abundant. Sopor or delirium may be present. Broncho- 
pneumonia and pulmonary gangrene result from the inhalation of putrid 
material from the mouth, and the disease usually terminates fatally in 
a few weeks, the course being that of a septicaemia. 

Treatment. — The treatment of aphthous stomatitis and that of ulcer- 
ative stomatitis are practically the same. Any derangement of the health, 
and especially of the digestive organs, must be carefully corrected. The 
individual ulcers may be touched with a point of solid silver nitrate, care 
being exercised to avoid the sound mucous membranes. Borax is often 
a useful application, but potassium chlorate is much more effective. Its 
influence is probably altogether local, but, as it is freely eliminated with 
the saliva, it is better to give it internally, to maintain a steady applica- 
tion. From three to five grains of the dry powder, with a little sugar, 
may be put upon the diseased mucous membrane every two to four hours 
in the case of a child j from five to ten grains for an adult. Thymol 
mouth-washes are sometimes comforting. 

Parasitic stomatitis, or thrush, is to be chiefly overcome by the careful 
treatment of the condition upon which its existence depends. Frequently 
it remains incurable so long as the hygienic surroundings of the child are 
not of the best character ; in bad cases it may be necessary to give the 
child breast-milk. If artificial feeding be maintained, it is essential that 
the mouth of the child, the nipples, and the bottles be kept as clean as 
possible. Solution of sodium sulphite (a drachm to the ounce), of boric 
acid (saturated), or of potassium permanganate (five grains to the ounce), 
may be applied locally after each feeding. 

Gangrenous stomatitis is especially a disease of extreme prostration 
and exhaustion, so that stimulants and very careful feeding form the 
basis of its treatment. The sloughing portions are to be destroyed by 
one of the strong acids, or, what is probably better, by the cautious ap- 
plication of Paquelin's or of an electro- thermic cautery ; subsequently 
antiseptics, especially thymol and carbolic acid, should be freely used. 
The child should be kept in the open air day and night, as far as prac- 
ticable. 

GLOSSITIS. 

Definition. — Inflammation of the tongue. 

Inflammation may affect independently the surface and the paren- 
chyma of the tongue. Superficial glossitis usually occurs in the various 
forms of acute stomatitis, but a series of changes are at times to be found 



794 



DISEASES OF THE DIGESTIVE APPARATUS. 



which are usually regarded as evidences of chronic inflammation. Among 
these is the loss of epithelium in spots and patches, leading to more or 
less extensive erosion of the surface of the tongue, which becomes irregu- 
larly outlined, the lines upon a map being suggested, whence the term. 
geographic tongue. This variety of glossitis is found especially among 
infants and young children, and has been regarded as evidence of a dis- 
turbance of innervation as well as a manifestation of inflammation. In 
adults the occurrence of a somewhat similar affection has been described 
by Moller, and is accompanied by a sensation of heat and digestive dis- 
turbances. The dissected tongue is a congenital alteration characterized 
by deep furrows upon the surface, in consequence of which deformity 
of the tongue results. 

Buccal leukoplakia is also to be regarded as a variety of superficial 
glossitis, and is characterized by the presence upon the back and edges of 
the tongue of slightly elevated, more or less rounded, somewhat trans- 
lucent patches of an opaque gray color. They are due to enlargement of 
the papilla and to the excessive formation and accumulation of epidermis. 
Other terms which have been applied to this condition are ichthyosis, 
psoriasis, and keratosis of the tongue. Excessive smoking is usually con- 
sidered to be the commonest cause, and many observers have regarded it 
as a manifestation of syphilis. The latter view is opposed by the frequent 
lack of other evidence of syphilis and by the failure of antisyphilitic 
treatment to afford relief. It is possible, however, that the syphilitic 
patient may be more prone to this affection in consequence of an increased 
vulnerability of the mucous membrane, either from the frequent localiza- 
tion of syphilitic lesions in the mouth or from the effects of mercurial 
treatment. The white patches last for months or years and obstinately 
resist treatment. In repeated instances cancer has developed from the 
diseased patch. The treatment consists in the careful removal of any 
source of local irritation, in the thorough treatment of digestive disturb- 
ances, and in the local application of mild stimulating solutions. The 
best of these is probably that of chromic acid, three to five grains to the 
ounce. 

PARENCHYMATOUS GLOSSITIS. 

Parenchymatous glossitis is a relatively rare affection, characterized 
by enlargement of the whole, more rarely of one-half, of the tongue, 
which may protrude from the mouth or cause it to be kept constantly 
open. Slight degrees of acute parenchymatous glossitis occur in stoma- 
titis. Extreme degrees, however, represent a local infection of the tongue, 
as in foot-and-mouth disease or in consequence of injury or of poisoning 
from the stings of insects. The enlargement of the tongue is due to 
the presence of an increased quantity of lymph or of pus, according to 
the severity of the process, in the interstitial tissue. There are prostra- 
tion, fever, and difficulty of talking, swallowing, and breathing. The 
tongue is painful, saliva flows from the mouth, and the neighboring 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 795 

lymph-glands are swollen. Acute parenchymatous glossitis ends in reso- 
lution or in the formation of an abscess. 

An acute wdematous enlargement of the tongue, accompanied with a 
burning sensation, sometimes occurs both in children and in adults in 
consequence of disturbance of gastric digestion. This is closely allied 
to giant urticaria, and is easily to be discriminated from acute inflam- 
matory enlargement of the tongue by the rapidity of its onset, its brief 
duration, and the absence of constitutional disturbance. 

Chronic parenchymatous glossitis results from repeated attacks of 
acute inflammation, and may lead to considerable enlargement of the 
tongue, associated with excessive salivation, and causing difficulty of 
speech and swallowing. Pressure of the enlarged tongue against the 
teeth may lead to ulceration, and has required extraction of the teeth. 
Myxedematous enlargement is a rare variety of chronic glossitis, and 
its nature is to be recognized by the evidences elsewhere of myxoedema. 
A congenital enlargement of the tongue, — macroglossia, — essentially a 
cavernous lymphangioma, is to be discriminated from chronic glossitis 
by its occurrence at birth. 

Treatment. — In the treatment of acute glossitis, ice should be con- 
tinually applied to the inflamed tongue. If the swelling be very severe, 
longitudinal scarification sometimes gives relief. If pus forms, it should 
be at once freely evacuated. In rare cases tracheotomy is necessitated by 
the interference with the respiration. 

RANULA. 

This term is applied to the deformity produced by a cystic tumor in 
the floor of the mouth containing a slimy fluid and giving an appearance 
which suggests the mouth of the frog. The cyst, sometimes of consider- 
able size, lies below and at the side of the tongue, which is carried towards 
the roof of the mouth : the effect upon speech, swallowing, and respiration 
is essentially that resulting from enlargement of the tongue. Several 
explanations have been offered for the occurrence of the cyst. According 
to some authorities, obstruction of the ducts from the sublingual or sub- 
maxillary glands is the cause. Von Recklinghausen considers closure of 
the ducts of Blan din's glands, which lie beneath the tip of the tongue, to 
be the essential feature in etiology. It has been suggested also that the 
cyst may arise from the bursa mucosa found by Fleischmann at the side 
of the fraenum. It is thus probable that several distinct conditions are 
included under ranula. In general, the deformity is persistent, but we 
have seen it occur in connection with stomatitis, last a few days, and then 
quickly subside. 

Treatment. — The only treatment of chronic ranula is surgical. 
Three methods are in vogue : first, partial excision of the sac ; second, 
the introduction of the seton ; third, the injection of irritant fluids. Of 
these the first is to be preferred, though a second operation is often 



796 



DISEASES OF THE DIGESTIVE APPARATUS. 



required. The seton and injection methods are apt to be accompanied by 
closure of the opening and danger of septic infection. When the ranula 
is an acute retention cyst, the treatment is that of catarrhal stomatitis. It 
disappears as the swelling of the duct subsides. 

INFLAMMATION OF THE SALIVARY GLANDS. PAROTITIS. 

Inflammation of the parotid gland, as a rule, arises from the advance 
of an inflammatory, probably bacterial, irritant from the mouth along the 
duct of Stensen. In most cases the irritant is the agent which causes the 
infectious and contagious disease mumps. The excitant of the parotid 
inflammation may be admitted to the gland also by means of the blood- 
vessels. Parotitis occurs as a secondary condition in a number of in- 
fectious diseases, especially in typhoid fever, typhus fever, measles, scar- 
latina, and pneumonia, and in the traumatic infections, including puer- 
peral sepsis. 

The enlarged gland varies in appearance according to the severity 
of the disease. The lobules are red, reddish gray, or yellow, according 
as the presence of blood or that of pus is the more conspicuous. The 
interstitial tissue is swollen, and either gray and translucent or opaque 
yellow, according as the contained exudation is serous or purulent. 
Abscesses may eventually be formed, and appear on the surface of the 
gland as opaque yellow spots, which may prove the source of a puru- 
lent infiltration of the surrounding tissue. This may extend upward 
into the auditory meatus, or into the cranial cavity through the glenoid 
fossa, or inward into the mouth or the pharynx, or outward to the skin. 

Secondary inflammation of the parotid is manifested by a tender, 
painful swelling in the region of the parotid gland. The pain rapidly 
becomes severe, and the swelling produces a marked deformity of the 
region affected. There are high fever and decided prostration. Talking 
and eating are painful, and the pain often extends to the ear. 

When the inflammation ends in suppuration, the abscess may break 
through the skin or the pus escape from the auditory canal or from the 
mouth. Extension of the suppuration to the cranial cavity causes head- 
ache, delirium, perhaps convulsions, and sopor suggestive of meningitis. 

Secondary parotitis has a grave prognosis, and, even if recovery 
results in consequence of appropriate surgical treatment or of sponta- 
neous evacuation of the pus, permanent deafness may follow from the 
complicating otitis, and facial paralysis occur from the extension of the 
inflammation to the facial nerve in its course through the gland. 

INFLAMMATION OF THE SUBMAXILLARY AND SUBLINGUAL 

GLANDS. 

As a rare condition in mumps the inflammation of the salivary glands 
may be limited to the submaxillary or sublingual glands. Usually the 
inflammation of these glands is extended from the mouth in the severer 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 797 

variety of stomatitis, although it may be localized in the glands without 
any primary buccal disturbance. Its possible occurrence as a compli- 
cation in infectious diseases, as diphtheria and scarlet fever, should be 
remembered. 

A painful, tender swelling makes its appearance in the posterior sub- 
maxillary region, and is associated with fever and difficulty of speaking 
and eating, in part in consequence of the elevation of the tongue and in 
part from the pain on motion of the muscles. The inflammation may end 
in resolution in the course of a fortnight, more or less, or extend to the 
tissues around the gland, in which case a deep-seated lymphangitis 
follows, terminating in suppuration or gangrene. This phlegmonous 
lymphangitis or cervical cellulitis has been designated angina Zaidovici, 
Ludwig's angina, from the name of the physician who first called con- 
spicuous attention to it. It is of rare occurrence, occasionally as an 
epidemic, and has been regarded by some writers as a disease sui generis. 

It is characterized by a dense swelling which makes its appearance 
beneath the jaw and in the upper part of the neck and may cause oedema 
of the larynx or pressure upon the trachea. The fever becomes more 
extreme and assumes a typhoidal course indicative of a severe septicaemia. 
The lymphangitis may extend downward into the mediastinum and 
pleurisy or pericarditis follow, or, if suppuration is present, the pus may 
reach the surface and the abscess open through the skin or into the mouth 
or the pharynx. The prognosis of the severer forms is extremely grave. 

Treatment. — In acute inflammation of the parotid or other salivary 
glands, not due to mumps, an attempt may be made, by the application 
of leeches followed by ice, to arrest inflammation ; if, however, suppu- 
ration occurs, the affected parts should be freely opened and afterwards 
receive the treatment of a septic inflammation. 

From a therapeutic point of view, at least, Ludwig's angina is a 
surgical disease, the principles of whose treatment are the use of early 
and ample incision, with rigid antisepsis, and general support by feeding 
and medication. As has been especially insisted upon by Gerster, it 
is probably best to make a careful dissection of the submaxillary region, 
with a final incision through the mylo-hyoid muscle, followed by repeated 
thorough irrigation with a saturated solution of boric acid or with solu- 
tion of corrosive sublimate one to one thousand, or with a hydrogen 
peroxide solution. 

inflammation of the pharynx and the tonsils. 

Inflammation of the pharyngeal mucous membrane, angina, although 
usually associated with that of the tonsils, the superficial lymph-glands 
of the pharynx, may occur without any involvement of the latter : hence 
a clinical distinction is usually made between pharyngitis and tonsil- 
litis, according to the more conspicuous localization of the inflammatory 
process, although there is often no difference in etiology. 



798 



DISEASES OF THE DIGESTIVE APPARATUS. 



ACUTE PHARYNGITIS. 

Etiology. — A primary pharyngitis is to be distinguished from the 
secondary inflammation of the pharynx occurring in acute infectious 
diseases, as measles, scarlet fever, variola, influenza, and diphtheria, or in 
chronic infections, as syphilis. The primary affection is especially fre- 
quent among children, is usually attributed to exposure to cold, and 
is often associated with a nasal or a laryngeal catarrh ; but it is prob- 
able that infection also plays an important part in the etiology. Bac- 
teria are always present in the pharynx, and it is not unlikely that 
exposure to cold may offer favoring opportunities for their admission 
to the tissues. The frequent occurrence of epidemics of pharyngitis 
and tonsillitis also points towards an infectious origin, and the occa- 
sional succession of cases within a short time and in the same family is 
suggestive of its contagious nature. Local irritants are of importance, 
and the influence of faulty drainage in the development of pharyngitis 
and tonsillitis is often apparent. Some writers assert that gout and 
rheumatism are productive of inflammation of the pharyngeal mucous 
membrane, and that in acute articular rheumatism, in particular, inflam- 
mation of the tonsils is a frequent complication. Pharyngitis and 
tonsillitis, however, are affections of extraordinary frequency, and their 
occasional occurrence in rheumatism and in gout is to be expected. In 
our experience they are not so common in these affections as to seem 
dependent upon them. Inasmuch as acute articular rheumatism is prob- 
ably an acute infectious disease, a localization of the infectious cause 
might be expected as well in the pharynx as in other parts of the body, 
and with as much reason as in typhoid fever or scarlet fever. Such 
localization, however, is decidedly infrequent. 

Symptoms. — Pharyngitis is acute or chronic, superficial or deep- 
seated. Superficial pharyngitis is a catarrhal inflammation, the deep- 
seated variety is phlegmonous. 

Acute catarrhal pharyngitis (simple sore throat) may occur without 
any especial warning, and is not infrequently preceded by the symptoms 
of a mild nasal or laryngeal catarrh. It is often announced by chilliness 
followed by slight elevation of temperature. As a rule, there is but little 
constitutional disturbance ; at the most, slight headache, backache, and 
loss of appetite. The soreness of the throat is early made apparent by 
discomfort in swallowing and by a sense of dryness. The soft palate and 
the uvula are reddened and moderately swollen, and the posterior wall 
of the pharynx is congested, perhaps covered with a layer of opaque 
gray mucus. The severer manifestations of acute catarrhal pharyn- 
gitis are associated with conspicuous alteration of the tonsils, and will 
be described in connection with tonsillitis. 

Acute pharyngeal catarrh is usually a trivial affection, running a mild 
course, lasting for a day or two, and not necessarily interfering with the 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 799 

daily vocation of the patient. It is important only as probably repre- 
senting the mildest stage of what may prove a severe disease, and it 
is always to be remembered that during the first twenty-four hours 
there may be no means, other than bacteriological, by which a simple 
catarrhal sore throat can be absolutely distinguished from a diphtherial 
sore throat. 

In phlegmonous pharyngitis the irritant invades the submucous tis- 
sue and causes an acute oedema or a purulent infiltration which rapidly 
extends throughout the pharynx. There are great elevation of tempera- 
ture, quick pulse, rapid respiration, pain in swallowing, hoarseness of 
the voice, and dyspnoea. The uvula, the soft palate, the palatine arches, 
the mucous membrane of the posterior pharyngeal wall, and perhaps the 
tonsils, are greatly swollen and livid. The neck is enlarged, painful 
on motion, and the submaxillary lymphatic glands are increased in size 
and tender. Death may occur suddenly from oedema of the glottis, or 
the inflammation may extend downward towards the mediastinum, as in 
inflammation of the submaxillary glands, and a complicating pleurisy or 
pericarditis result, or the pus escape by the mouth or through the skin. 

In young children, especially, phlegmonous pharyngitis assumes the 
characteristics of an acute retropharyngeal abscess. The difficulty of 
swallowing, the rigidity of the neck, the altered voice, and the labored 
breathing are associated with a fluctuating swelling of the posterior 
pharyngeal wall. The chronic retropharyngeal abscess also causes a 
fluctuating tumor in this region, but it is usually the result of caries of 
the cervical vertebrae, and the severe symptoms of acute pharyngitis are 
lacking. 

Treatment. — In the mildest cases of acute pharyngitis it is only 
necessary to swab the throat out twice a day with glycerite of tannin, 
or to apply carefully a solution of silver nitrate twenty to forty grains 
to the ounce, or to use a gargle of rhus glabra (formula 21) every three 
to four hours. In severer cases, with fever, a quarter of a grain of 
calomel should be given every two hours until it purges freely ; three to 
five drops of belladonna should be administered four times a day, unless 
dryness of the mouth supervene, when the dose should be reduced ; and 
the glycerite of tannin or the gargle should be used every two hours. A 
local application of a strong solution — forty grains to the ounce — of 
silver nitrate may be useful. The external application of the ice-collar 
and the free, continuous use of cracked ice is often very serviceable. 
Five to ten grains of quinine may also be given daily. 

The diet should be light but nutritious. Milk and milk foods, broths, 
and farinaceous foods should be chiefly taken. Ice-cream is especially 
grateful. Meat should be allowed very sparingly, if at all. 

A retropharyngeal abscess should be surgically evacuated as soon as 
the diagnosis is clear. In most cases it is probably better to make the 
incision from without rather than through the wall of the pharynx. 



800 



DISEASES OF THE DIGESTIVE APPARATUS. 



Violent hemorrhage from an erosion of a large blood-vessel is almost 
always fatal, though life has been saved by an immediate tying of the 
common carotid. 

CHRONIC CATARRHAL PHARYNGITIS. 

Chronic inflammation of the mucous membrane is the frequent result 
of repeated attacks of acute pharyngeal catarrh, but is due also to pro- 
longed local irritation of the throat, either from tobacco, alcohol, and 
highly seasoned food, or from excessive use of the voice, — for example, 
by clergymen. Chronic passive congestion of the mucous membrane in 
obstructive cardiac and pulmonary disease is likewise a cause. 

The throat is usually dry, but there is often a tickling sensation from 
the elongated uvula or a feeling as if secretion were dropping from the 
naso-pharynx. The patient awakes at night with a choking sensation, 
and on rising makes repeated efforts to clear the throat from a tenacious 
secretion which frequently forms a crust upon the posterior pharyngeal 
wall. Hawking is frequent during the day for the same purpose, and the 
voice is usually husky. The mucous membrane either is congested, re- 
dundant, and flabby, with visible enlargement of the veins and a coarsely 
granular appearance of the surface from hypertrophy of the lymph- 
follicles, or is pale, thin, tense, and shining from atrophy,— pharyngitis 
sicca. Chronic pharyngitis is an obstinate affection, subject to exacer- 
bations and periods of temporary relief, but in the adult is extremely 
resistant to all attempts at permanent cure. The extension of the in- 
flammation to the nostrils, Eustachian tube, and larynx is frequent, and 
headache, deafness, chronic cough, and permanent alteration of the voice 
often result. 

In children, chronic catarrhal pharyngitis is especially characterized 
by the enlargement of the lymph-follicles in the mucous membrane of 
the roof and posterior wall of the naso-pharynx, in which they form 
reddish-gray, fleshy masses either nodular or papilliform, perhaps pedun- 
culate, frequently filling the pharyngeal vault and interfering with nasal 
respiration. The secretion from the inflamed surface is abundant, and 
is usually swallowed. These li adenoids," or enlarged pharyngeal tonsil, 
are a frequent cause of mouth-breathing, and in children so affected 
the mouth is constantly open, the lips are thickened and everted, and 
the expression is one of stupidity. There are snoring, a thick voice, 
and frequent mental and physical sluggishness. With the persistence 
of this follicular pharyngitis the roof of the mouth becomes narrowed 
and raised. Nasal and auditory catarrh are often associated, and head- 
ache, and impairment of the senses of smell, taste, and hearing, are 
likely to follow. Deformity of the thorax may result, the upper part 
of the chest being distended, the lateral regions corresponding to the 
insertion of the diaphragm being depressed. Children with adenoids 
are liable to attacks of nightmare, and may suffer from asthma. 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 801 

Treatment. ■ — In the treatment of chronic pharyngitis it is essential, 
if possible, to remove the cause. Thus, in many cases cure cannot be 
obtained until the subject ceases from smoking or the use of tobacco, 
or from the taking of strong alcoholic drinks or highly spiced food, or 
from an excessive and improper use of the voice. Again, it may be 
necessary, by general treatment, by hygienic management, or by travel, 
to build up the general health. Locally, markedly hypertrophied parts 
may be touched by the gal vano- cautery, whilst solutions of tannic acid or 
silver nitrate or chromic acid, and of the various other local remedies, 
are regularly applied. 

Adenoid growths occurring in the pharynx — the so-called pharyngeal 
tonsil — should always be removed at once, as, if left, they often seriously 
affect the general health of the child, and as other than radical measures 
are of no avail. The child should be anaesthetized, and the adenoid 
tissue scraped off with the finger-nail or a curette. If, after removal of 
the cause, the habit of mouth-breathing which has been formed persist 
during sleep, the jaw should be kept up by a chin- strap. In most cases 
general hygienic treatment of the child is necessary. 

TONSILLITIS. 

As already stated, tonsillitis is to be considered as a form of pharyn- 
gitis in which the superficial lymph -glands of the pharynx — namely, the 
tonsils — are especially altered, and the infectious varieties of pharyn- 
gitis are those especially concerned in the production of acute inflamma- 
tion of the tonsils. Acute tonsillitis is to be distinguished from chronic 
tonsillitis, and is the variety to which the terms follicular and lacunar 
tonsillitis have been applied. It is generally known, especially in con- 
sequence of the observations of Stohr, that the tonsils are covered with 
mucous membrane which extends into and lines the recesses, crypts, or 
lacunae, the walls of which are studded with lymph-follicles, and in which 
a few mucous glands are to be found. It is in virtue of the relation of 
the inflammatory product to the lacunse that the term lacunar tonsillitis 
is applied. 

acute tonsillitis. 

Acute tonsillitis usually begins with a chill, sometimes violent, fol- 
lowed by fever, the temperature rising rapidly to 103° F. and upward, 
and associated with headache, backache, pains in the bones, and mus- 
cular weakness. There is loss of appetite, with mental and physical 
prostration, and wakefulness is often present. Pain in swallowing is 
soon manifested, and rapidly increases. At the outset the mouth is 
dry and the tongue coated, but later there is an increased flow of saliva 
from the mouth, largely in consequence of difficulty in swallowing. On 
examination of the throat, in addition to the general swelling and con- 
gestion of the pharynx, a conspicuous enlargement of one or of both 
tonsils is apparent. The enlarged and reddened tonsils may almost 

51 



802 



DISEASES OF THE DIGESTIVE APPARATUS. 



wholly fill the opening of the pharynx, and soon become covered with 
a thin, in part translucent, in part opaque gray, film which apparently 
exudes from the crypts and becomes confluent. At the opening of the 
crypts are to be seen opaque white spots, which are composed of leuko- 
cytes, bacteria, and particles of food. The lymph-glands at the angle 
of the jaw are swollen and tender on one or both sides, according as 
one or both tonsils are inflamed. Pain extending into one or both 
ears and impairment of hearing are not infrequently associated. Albu- 
minuria is frequently found. 

In mild cases of tonsillitis convalescence usually begins in three or 
four days, and the swelling of the tonsils and difficulty of swallowing 
disappear in the course of a week. In the severest cases of tonsillitis, 
to which the term quinsy is especially applied, an abscess forms in the 
inflamed tonsil. On the third or fourth day of the tonsillitis there is 
no diminution in the severity of the symptoms, but the enlarged and 
resistant tonsil becomes soft and fluctuant. The abscess may break sud- 
denly, usually into the mouth or the pharynx, when the local symptoms 
often at once disappear and rapid relief to the constitutional disturbance 
follows. In rare instances the pus has entered the larynx, causing suffo- 
cation, and still more rarely the suppurative inflammation has extended 
to the internal carotid artery, which has been perforated. 

Treatment. — The treatment of acute catarrhal tonsillitis is the same 
as that already given for acute pharyngitis. It is believed by many 
practitioners that both this form of tonsillitis and suppurative tonsillitis 
are often of rheumatic origin, to be benefited by the use of salol or the 
salicylates. 

In quinsy, to avoid the formation of pus all that can be done is to 
cleanse the throat with a very dilute solution of hydrogen peroxide, or 
a thymol mouth-wash, often preferably used by spray, and to soothe the 
irritation by the free internal and external use of ice. Temporary relief is 
sometimes afforded by scarification of the tonsils, and certainly any pus 
should be evacuated as soon as it has formed. If the abscess is in the 
soft palate, a little above and on the outside of the margin of the tonsil, 
the incision should be through the soft palate, just outside of and parallel 
to the anterior pillar, and in the neighborhood of the line of the upper 
margin of the tonsil. If the tendency is for the pus to escape through 
the crypt of the tonsil, the incision should be into the tonsil, as near as 
possible to the natural outlet of the pus. When the pus burrows down- 
ward it is often most difficult to reach, and in some cases when there is 
much swelling even an external incision may be necessary. 

The diet should be as nutritious as possible. Ice-cold foods can often 
be swallowed when even ordinary warm liquids are rejected ; hence ice- 
cream is often very grateful to the patient. 

For the relief of pain opiates should be used, and if there be sleep- 
lessness at night, sulphonal, trional, or other of the minor somnifacients. 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 803 



CHRONIC TONSILLITIS. 

Chronic inflammation of the tonsils is of especial frequency in feeble 
children, although not limited to them, and its results are particularly 
apparent at or about the age of puberty. The vulnerability of the ton- 
sils may be inherited, and chronic tonsillitis is often seen in scrofulous 
children, in whom enlargement of the lymph-glands elsewhere is likely 
to be associated. Its usual exciting cause is a recurrence of attacks 
of acute tonsillitis or pharyngitis, whether of primary or of secondary 
origin. The inflammation affects the surface or the substance of one 
or both tonsils. 

The symptoms of superficial chronic tonsillitis are those of chronic 
pharyngitis. The affection is characterized by the presence of opaque 
white plugs encircled by congested mucous membrane and projecting 
slightly from the surface of the tonsil. These form casts of the crypts 
in which they lie, are often of the size of grape-seed, and have a smooth, 
rounded surface and frequently a blunt-pointed end. They are ex- 
tremely offensive when crushed, and are composed of degenerated cells, 
fat-crystals, bacteria, fat-drops, and perhaps starch-granules. They give 
rise to a tickling or pricking sensation, and eventually either are swal- 
lowed or are expelled by vigorous hawking or coughing. A gap — the 
distended crypt — remains, which soon becomes narrow. More rarely 
these cheesy plugs are long retained, become infiltrated with lime salts, 
and form the tonsillar calculus. 

When the entire tonsil is inflamed, enlargement results, due to hyper- 
plasia of the cells and increase of the fibrous tissue, the consistency of 
the tonsil being modified by the predominant increase of the one or the 
other element. The tonsil varies in size from that of a walnut to that 
of a pigeon's egg, is rounded and elongated, either pedunculate or with a 
broad base, and the surface is usually smooth, though sometimes irreg- 
ular. Enlargement of the tonsil causes obstruction of the fauces, which 
becomes almost complete when both tonsils are enlarged. The speech 
is thick, the voice is nasal. There is but little disturbance in swallow- 
ing, and the breathing is only slightly affected unless the lymph-follicles 
of the pharynx are also enlarged. The latter condition, however, is fre- 
quently combined with enlargement of the tonsils, and the symptoms 
of chronic follicular pharyngitis are then associated with those due to 
chronic tonsillitis. Children with enlargement of the tonsils are subject 
to frequently recurring acute attacks of tonsillitis and pharnygitis, and, 
when exposed to diphtheria, become infected more readily than children 
with normal tonsils. 

After the age of puberty both the enlarged tonsils and the hyperplastic 
pharyngeal follicles usually become diminished in size and cease to be 
productive of disturbance. The popular idea that the removal of the 
tonsil is a cause of atrophy of the testicle is erroneous. 



804 



DISEASES OF THE DIGESTIVE APPARATUS. 



Treatment. — In the treatment of chronic tonsillitis the indication is 
especially to reduce the size of the tonsil. The attempt at this by the 
application of powdered alum, by tincture of iodine, and by other local 
remedies is very rarely successful. The tonsil may, however, be slowly 
destroyed by caustic or by the application of the electro -cautery ; though 
there is no reason for believing that better results are obtained by this 
slow and painful method than by the excision of the tonsil, an operation 
which, properly performed, is free from danger. 

DISEASES OF THE OESOPHAGUS. 
OBSTRUCTION. 

Etiology. — Obstruction of the oesophagus is the result of congenital 
malformation, stricture, tumors of the wall, foreign bodies, compression 
from without, and muscular spasm. Congenital stenosis occurs more fre- 
quently at the upper end of the oesophagus than near the stomach 5 in the 
former situation it is attributed usually to arrest of development, while 
the cause of its occurrence in the latter region is unknown. There may 
be no union of the upper end of the primitive intestine with the lower 
end of the pharynx, in which case atresia of the oesophagus results ; the 
communication between the oesophagus and the trachea sometimes exist- 
ing at birth is due, probably, to a like irregularity of development. 

Strictures of the oesophagus are of either inflammatory or malignant 
origin. The former result from the swallowing of corrosive fluids, injury 
from foreign bodies, the evacuation of perioesophageal abscesses or softened 
cheesy glands, or syphilis. Malignant disease, especially cancer, produces 
stricture by so infiltrating the wall as to prevent its distention, by the con- 
traction of the fibrous tissue of the cancer, or by projecting into the canal. 
Obstruction of the oesophageal canal may result from the presence of 
pedunculate polypi and various impacted foreign bodies, including the 
rare accumulation of the o'idium albicans in thrush. Obstruction of the 
oesophageal canal also results from the pressure upon the oesophagus from 
without of tumors, distended oesophageal diverticula, perioesophageal ab- 
scesses, and aneurism of the aorta. In obstruction from muscular spasm 
the symptoms are not associated with any organic lesion. 

Symptoms. —The essential symptom of obstruction of the oesophagus 
is difficulty of swallowing, which is greater for solids than for fluids. 
One or several mouthfuls may enter the oesophagus before regurgitation 
takes place. This may be easy, or the efforts at expulsion in case of 
impacted solids may produce asphyxia, emphysema of the subcutaneous 
tissues, and even rupture of the oesophagus. The progress of stenosis 
of the oesophagus depends upon the nature and extent of the obstruction 
and the degree of compensatory hypertrophy. 

Diagnosis. — The diagnosis is based upon the history of gradually 
increased dysphagia, especially as indicated by the delay in the passage 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 805" 



of food from the niouth to the stomach. This is manifested on physical 
examination by the retarded oesophageal gurgle, which, according to 
Meltzer, is normally to be heard at the left of the ensiform cartilage, or 
of the spine near the tenth rib, about six seconds after food or liquid is 
swallowed. The seat of the obstruction is to be determined by the use 
of the oesophageal sound or tube. The former consists of a long, flexible 
handle of whalebone or steel, to which an olive-shaped tip is securely 
fastened, or resembles in composition a magnified urethral bougie. The 
tube is essentially the same as that employed for the purpose of removing 
the contents of the stomach, is about as large round as the little finger, 
and has a rounded or blunt-pointed end, which is either solid or hollow. 
Before passing the sound or tube it is important to eliminate the possi- 
bility of an aortic aneurism as the cause of obstruction, and the existence 
of varicose veins from fibrous hepatitis, since immediately fatal or pro- 
fuse hemorrhage may follow rupture of the aneurism or laceration of 
the veins. The attempt at passing the sound or tube may give rise to 
asphyxia or collapse in a person with cardiac disease, and be productive 
of extreme discomfort in a nervous person. In passing the sound the 
patient should sit upright, with the head slightly thrown backward, that 
the cavities of the mouth, pharynx, and oesophagus may lie as nearly in 
a straight line as possible. As the tip of the sound or tube touches the 
posterior pharyngeal wall, the patient should make an attempt to swallow 
and should be encouraged to breathe. Under ordinary circumstances the 
tube or sound readily passes downward in the oesophagus until the seat 
of the obstruction is reached. If spasm of the faucial and pharyngeal 
muscles resists the entrance of the tip of the sound, the application of 
cocaine will relieve the sensitiveness of the mucous membrane. The dis- 
tance from the incisor teeth to the stomach is about seventeen inches, and 
the seat of the obstruction is to be determined, after the advance of the 
tube is stopped, by fixing the point at which it is in contact with the 
incisor teeth, and measuring the distance from this point to the tip of the 
tube after its withdrawal. The use of the cesophagoscope in the explora- 
tion of the oesophagus gives but little information additional to that which 
may be obtained by the tube or sound. 

The nature of the cause of the obstruction is to be determined by 
the history of the case, by the associated symptoms, and perhaps by the 
removal of portions of a tumor by means of the sound or by their escape 
during vomiting. The Eontgen rays may aid in detecting and locating 
a foreign body in the oesophagus. 

Prognosis. — The prognosis depends upon the cause of the obstruc- 
tion. Infants born with atresia of the oesophagus die in the course of a 
week, either from starvation or from pneumonia following the inhalation 
of food into the air- passages. Cicatricial strictures are grave in propor- 
tion to their density and the length of the wall involved, but are fre- 
quently capable of being so dilated that the patient can live in comfort. 



806 



DISEASES OF THE DIGESTIVE APPARATUS. 



The prognosis of malignant strictures of the oesophagus is especially con- 
sidered on page 814. Obstruction from foreign bodies usually offers a 
favorable prognosis even when there is impaction, since repeated oper- 
ations of late years have shown that impacted foreign bodies resisting 
attempts at removal through the mouth may be reached and removed 
through either an incision in the neck or an opening in the wall of the 
stomach. Stricture of the oesophagus from spasm, although often obsti- 
nate, is usually not directly injurious to life or health. 

Treatment. — Organic stricture of the oesophagus is a surgical dis- 
order, to be treated by mechanical means ; if the case be not malignant, 
by methodical and gradual dilatation by means of bougies. A flexible 
bougie should always be employed, finished at the end with an olive- 
shaped ivory tip. It may be that at first only the catgut bougie can be 
passed through the narrowed channel ; but even in such a case persistent 
very gradual and gentle dilatation will often finally bring about a bril- 
liant result. For the method of using the sound, see Diagnosis. In 
many cases the best results are obtained by teaching the patient to pass 
the bougies himself. When there is ulceration or inflammatory soften- 
ing of the oesophagus there is always danger of making a false passage, 
with serious and, it may be, rapidly fatal results. 

The question of feeding is always dominant. If even the smallest 
tube can be got through the stricture, various liquid foods should be given 
at regular intervals. If it be impossible to nourish the patient in this 
way, nutritive enemata should be used. (Esophagotomy or gastrostomy 
may be performed for the purpose of sustaining life. 

Spasmodic stricture of the oesophagus commonly occurs in hysterical 
subjects, and is chiefly to be met by the treatment of the underlying con- 
stitutional neurotic condition. Antipyrin, bromides, and similar remedies 
are used for temporary relief. When, as is frequently the case, there is 
great psychical impressionability, a cure may be wrought by psychical 
impressions, so that even a single passage of the oesophageal bougie may 
suffice for permanent relief. 

In cancerous disease of the oesophagus mechanical treatment of the 
stricture is sometimes of benefit, but should be so practised as to avoid 
giving pain. Surgical interference has thus far not yielded good results, 
death being apparently inevitable. 

DILATATION. 

Dilatation of the oesophagus is either diffuse, ectasis, or circumscribed, 
diverticulum. 

Ectasis is primary or secondary, the former being a rare condition 
due apparently to muscular weakness of unknown origin, and occurs 
both in infants and in adults. This variety of dilatation generally in- 
volves a considerable extent of the oesophagus, the tube often being 
increased in length and somewhat tortuous. The wall usually is thick- 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 807 

ened, but sometimes is abnormally thin. Secondary ectasis is the result 
of stenosis, and arises after the compensatory hypertrophy of the wall is 
replaced by a relaxed condition. The diffuse dilatation of the oesophagus 
is associated with retention and subsequent regurgitation of food, and the 
breath is offensive from the decomposition of the retained food. The 
passage of the sound meets with no obstruction, unless the canal is very 
tortuous, and the tip moves about with unusual freedom before reaching 
the stomach. 

Diverticulum. — According to Zenker and Von Ziemssen, two vari- 
eties of diverticulum, the pulsion and the traction diverticulum, are 
to be found in the oesophagus. The pulsion diverticulum is regarded by 
these authors as a hernia of the mucous membrane through a weakened 
portion of the muscular coat, caused either by injury, ulcer, or scar, 
and promoted by the act of swallowing. In opposition to this view it 
has been said that the pulsion diverticulum has never been observed in 
diphtherial paralysis, in which there is extreme muscular weakness. It 
has been suggested that the pulsion diverticulum is of possibly congeni- 
tal origin and represents the remains of a branchial cleft, and Fitz has 
offered evidence that it may represent a misplaced vitelline duct. In 
opposition to the theory of a congenital origin is the fact that this 
variety of diverticulum has never been found in the infant, and usually 
becomes apparent during middle life. 

The pulsion diverticulum is single, and arises from the posterior wall 
of the oesophagus, near the level of the cricoid cartilage. It is either 
globular or cylindrical, and after long continuance may be pear-shaped, 
several inches in length, and of large capacity. The opening into the 
oesophagus is narrow or wide, and sometimes the canal of the diverticulum 
appears as the direct continuation of the oesophageal canal, the lower 
end of the gullet apparently starting from the side of the diverticu- 
lum. The wall of the diverticulum contains a few muscular fibres near 
its origin from the oesophagus, but for the most part is composed of 
mucous membrane and fibrous tissue. The lining membrane is often 
granular or warty in consequence of the irritation of retained and de- 
composed food, but ulceration is rare. 

As the pulsion diverticulum becomes sufficiently enlarged from the 
retention of increasing quantities of food, a sense of local discomfort, 
perhaps associated with choking, and resulting in paroxysms of coughing, 
is occasioned by food first swallowed, but is relieved after more food is 
taken. Eegurgitation eventually occurs, sometimes of food which has 
been retained for weeks. The contents of the diverticulum may be re- 
peatedly regurgitated and returned before finally reaching the stomach. 
If the diverticulum is large, it may appear as a deep-seated tumor in the 
neck, the size of which varies from time to time and may be diminished 
by pressure. The passage of the oesophageal sound is often obstructed 
by its entrance into the sac, but if the opening into the latter is closed by 



808 



DISEASES OF THE DIGESTIVE APPARATUS. 



one or more sounds, the passage of a sound or tube into the stomach 
readily takes place. 

The disturbances produced by the diverticulum, as a rule, are per- 
sistent, and slowly increase in severity, the affection having proved a 
cause of death in about one-half of the recorded cases. 

The traction diverticulum is caused for the most part by contraction 
of chronic inflammatory adhesions between inflamed lymph-glands and 
the oesophagus. The immediate causes of the lymphadenitis are tuber- 
culosis, pleurisy, and caries of the rib or sternum. These diverticula may 
be multiple, short, funnel-shaped, and are to be found in that part of the 
oesophagus which is in the immediate vicinity of the tracheal bifurca- 
tion. Perforation of the oesophageal wall is likely to follow the retention 
and decomposition of food which lodges in the diverticulum. 

Traction diverticulum causes little or no disturbance, unless sufficiently 
large and so shaped that food may be caught, retained, and decomposed, 
in which case ulceration and necrosis may follow, resulting in perforation 
of a bronchus with subsequent broncho-pneumonia and gangrene from 
inhalation of food. The perioesophageal inflammation is likely to extend 
to the pleura or the mediastinum, and a septic pleurisy or mediastinitis 
then results. 

In diffuse dilatation of the oesophageal walls, as well as in the localized 
form of dilatation in which there are circumscribed pouches, no medical 
treatment is of any value. Feeding with the stomach-tube is necessary 
when the patient is not sufficiently nourished. 

PERFORATION. 

The oesophagus may be perforated from the mucous surface or from 
the outside of the wall. Perforation from within may be due to foreign 
bodies, which during their passage tear the oesophagus or become im- 
pacted and produce ulceration and necrosis of the wall. Caustic fluids 
also may produce a necrosis of the wall resulting in perforation, and 
ulcerating cancer may so progress as to perforate the oesophagus. Per- 
foration from the outside of the oesophagus oftenest results from the 
rupture of an abscess in the vicinity, as suppurating lymph-glands 
or an acute or chronic retropharyngeal abscess. Aneurism of the 
aorta at times perforates the oesophageal wall, and, rarely, a communi- 
cation has been established between the oesophagus and a cavity in the 
lung. 

The results of perforation of the oesophagus vary according to the 
nature and seat of the lesion and the presence or absence of communica- 
tion between the oesophagus and the lungs, pleura, pericardium, and 
mediastinum. In eighty-five cases collected by Zenker and Yon Ziems- 
sen the perforated oesophagus opened into the bronchi in twenty-six 
cases, into the lungs in twenty, into the trachea in twenty-one, into the 
pleural cavity in eleven, and into the pericardium in seven. 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 809 

There may be no symptoms calling attention to perforation of the 
oesophagus, or a pricking or tearing sensation with coughing or swallow- 
ing may occur. Eventually the symptoms become those of septicaemia, 
the physical signs indicating a localization of the inflammation in the 
lung, pleura, or mediastinum, the pus, when present, being coughed up or 
vomited. If perforation of the trachea or a bronchus has occurred, food 
may be raised from the larynx. Perforation of an aneurism is shown by 
the sudden hemorrhage, which is usually considerable and immediately 
fatal, though sometimes it may be slight and protracted from the presence 
of a thrombus in the aneurism. 

RUPTURE. 

In a few instances the oesophagus has been ruptured by severe mus- 
cular efforts made in the attempt to dislodge a foreign body which had 
become impacted in the gullet. Mackenzie considered that the sudden 
pressure against the oesophageal wall induced by the attempt at expelling 
a large quantity of material from the stomach might cause rupture. 
Previous softening of the oesophageal wall, if present, would undoubtedly 
act as a favoring cause. The evidence which has been presented of a 
primary softening of the oesophagus is in the main unsatisfactory and 
largely based upon the confounding of post-mortem softening with an 
ante-mortem lesion. The rent is longitudinal, perhaps two inches long, 
and probably results from the pressure of the contents of the stomach 
against an impacted body of such a nature as completely to close the 
oesophagus. Emphysema of the tissues is likely to occur, probably from 
rupture of the alveolar wall during the violent efforts at expelling the 
impacted body. In consequence of the rupture, which usually takes 
place into the posterior mediastinum, food enters the tissues, gangrene 
results, and, if the patient lives sufficiently long, an ichorous pleurisy is 
likely to follow and cause death from a septicaemia. 

Treatment. — Perforation or rupture of the oesophagus is so entirely 
without possibility of relief by medical means that, even with the total 
absence of guiding experience and statistics, surgical interference is justi- 
fiable. 

oesophagitis. 

Inflammation of the oesophagus is due to the admission of irritating 
material, whether foreign bodies, excessively hot liquids or solids, cor- 
rosive fluids, or frequent concentrated alcoholic drinks. Decompo- 
sition of retained food above a stricture or in a diverticulum also 
serves as a cause of inflammation. Oesophagitis may occur in the 
course of typhoid fever, scarlatina, variola, and tuberculosis or syphilis. 
Chronic passive congestion from valvular disease of the heart 1ms 
been considered of etiological importance. In rare instances inflam- 
mation has been extended into the oesophagus from the pharynx or the 
stomach. 



810 



DISEASES OF THE DIGESTIVE APPARATUS. 



Morbid Anatomy. — Since the lining membrane of the oesophagus 
resembles the skin in structure, the appearances of oesophagitis are 
analogous to those of a dermatitis, and in variolous oesophagitis typical 
vesicles and pustules are to be found. The usual anatomical varieties of 
acute oesophagitis are the desquamative, catarrhal, follicular, fibrinous, 
diphtheritic, and phlegmonous inflammations. Desquamative or exfolia- 
tive oesophagitis, oesophagitis dissecans superjicialis, is characterized by the 
detachment of more or less of the superficial portion of the membrane 
of the oesophagus as a cast of the tube. The detached portion is almost 
wholly composed of pavement epithelium. There are but few cases of 
this affection on record. We have seen it follow a dose of chloral given 
to an infant. 

In catarrhal oesophagitis there is also a detachment of epidermis rather 
in the form of curd-like masses than as flakes. In chronic catarrhal 
oesophagitis the mucous membrane is thickened, and warts may project 
or polypi hang from the wall. 

In follicular oesophagitis the sparse acinous glands are swollen, partly 
in consequence of retained secretion in the ducts and partly from the 
round- cell infiltration of the tissue in the vicinity. The fibrinous va- 
riety is characterized by the presence of a loosely adherent fibrinous 
membrane, and the diphtheritic variety by a necrosis of the superficial 
portion of the wall. Both of these varieties may occur in diphtheria, 
although it is rare for this disease to extend into the oesophagus. 

In phlegmonous oesophagitis the submucous fibrous tissue becomes in- 
fected either from within or from without the oesophagus, and a diffuse 
suppurative inflammation takes place which may result in the more or 
less complete detachment of the mucous membrane. The pus is usually 
discharged into the oesophagus through one or more openings, but some- 
times may find its way into the larynx or the trachea. 

Most important, in consequence of its frequency and severity, is cor- 
rosive oesophagitis, under which term are included the alterations due to 
the action of caustic acids and alkalies. In the milder cases only the 
superficial portion of the mucous membrane is affected, and the epi- 
dermis is shrivelled. If concentrated solutions of alkalies have been 
swallowed in large quantities, the mucous membrane is softened and 
gelatinous ; sulphuric acid causes it to become dry and black, and nitric 
acid makes it yellow. The action of the corrosive fluids may cause a 
complete destruction of the mucous membrane, and the exposed mus- 
cular coat is then shrivelled and traversed by a net- work of carbonized 
blood-vessels. If the patient live, the necrotic portions become sur- 
rounded by an inflammatory line of demarcation, and an injected zone 
infiltrated with leukocytes separates the necrotic from the normal tissue. 
At a later stage the necrotic portions are detached, and ulcers remain 
which lead to perforation or end in stricture. 

Pain in swallowing is the first discomfort of an oesophagitis, but may 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 811 

be absent in the exfoliative variety. It may be so severe as to cause 
regurgitation or lead to the avoidance of food. In the milder variety of 
inflammation the pain lasts usually but a few days. In severe oesopha- 
gitis the pain is more intense, the patient is unable to swallow, and motion 
of the neck is often so painful that the spine is kept rigid. There is 
fever, perhaps associated with chills, and the patient becomes exhausted. 
The region of the cervical portion of the oesophagus may be tender to 
the touch, and in case of perioesophageal suppuration the swelling may 
appear at the base of the neck on a level with the last cervical verte- 
bra. The abscess may cause displacement of the larynx or trachea, and 
dyspnoea and hoarseness be associated. The pus may be evacuated 
through the oesophagus or escape into the air- passages : in the latter case 
there is danger of suffocation or of broncho-pneumonia. In consequence 
of a communication between the oesophagus and the abscess, food may 
enter the latter and become decomposed, and gangrene of the tissues 
around the abscess result. 

Chronic oesophagitis is characterized by a sense of persistent aching 
or constriction in the region of the oesophagus, and by the frequent 
regurgitation of a viscid glairy fluid of an alkaline reaction, and some- 
times frothy, to which the term water-~brash is applied, and which is to 
be distinguished from the acid fluid regurgitated from the stomach in 
pyrosis. The act of swallowing may demand distinct muscular effort. 

Diagnosis. — Continued pain in swallowing, in connection with its 
method of origin, is the characteristic symptom of oesophagitis, the mild 
or severe nature of which is apparent from the associated symptoms. 
Exfoliative oesophagitis is diagnosticated by the ejection of detached por- 
tions of the epidermic layer of the lining membrane. 

Prognosis. — Eecovery from the milder varieties of acute oesopha- 
gitis readily and rapidly takes place. In the severer varieties of inflam- 
mation of the oesophagus, which are usually of corrosive or infectious 
origin, the prognosis is grave from the severity of the lesions and the 
tendency towards perforation, abscess, and gangrene. If recovery from 
acute symptoms takes place, the prognosis is that of fibrous stricture. 
Chronic catarrhal oesophagitis is resistant to treatment largely because 
of the persistence of its causes, and is liable to exacerbations and re- 
missions. 

Treatment. — There is no general medical treatment for oesophagitis. 
The food should be broths, milk and raw eggs, or other nutritious liquids, 
and in some cases must be given through the stomach-tube. Opium 
affords the only method of controlling extreme pain. Local remedies, 
such as bismuth subnitrate or solution of silver nitrate, may by swallow- 
ing be brought in contact with the oesophageal mucous membrane, but 
care must be exercised that no harm be done to the stomach by these 
remedies. When pus forms, surgical interference is justifiable, as in 
retropharyngeal abscess. 



812 



DISEASES OF THE DIGESTIVE APPARATUS. 



TUMORS OF THE OESOPHAGUS. 

Fibroma, lipoma, myoma, sarcoma, and cancer are the varieties of 
tumors to be found in the oesophagus. The fibroma in rare instances 
attains a large size, becomes polypoid, and causes obstruction. It arises 
from the anterior wall of the oesophagus in the vicinity of the cricoid 
cartilage, and has been found only in elderly people. Eetention cysts 
have been noticed repeatedly in chronic oesophagitis, and cysts sometimes 
occur near the oesophagus, their origin being attributed either to a per- 
sistent branchial fissure or to a detached, unusually high vitelline duct. 
Weigert has reported the occurrence of a polypoid adenoma which pro- 
duced no symptoms. 

CANCER OF THE OESOPHAGUS. 

Cancer is the most common form of tumor of the gullet, and is the 
most frequent cause of oesophageal disturbance. Zenker and Yon Ziems- 
sen state that it was found in one-quarter of one per cent, of some five 
thousand autopsies. 

Etiology. — Three-fourths of the cases occur in men, and four-fifths in 
persons between forty and sixty years of age, two-thirds of the patients 
being between the ages of fifty and sixty years. A certain etiological 
importance is to be attached to heredity and to local lesions, whether due 
to irregularity of development or to pathological processes. 

Morbid Anatomy. — Primary cancer is the variety generally found, 
although the disease sometimes extends from the stomach, pharynx, or 
thyroid gland. It is of the epidermoid variety, and is usually found at 
the narrowest portions of the oesophagus, either near the cricoid cartilage, 
in the vicinity of the bifurcation of the trachea, or at the lower end of the 
oesophagus. Authorities differ as to the greater frequency of the disease 
at the upper or at the lower third of the oesophagus. According to Car- 
malt, the cancer begins in the deeper layers of the lining membrane, from 
which it extends in all directions. At first an elevated, rounded, and 
flattened nodule appears, gradually increasing in length and breadth, 
sometimes by the formation and fusion of accessory nodules, and eventu- 
ally may encircle the oesophagus. Its extension in depth leads to the 
infiltration of the muscular coat, and the oesophagus is thereby trans- 
formed into an unyielding tube for a distance of one or two inches, 
sometimes throughout the length of the oesophagus. The growth also 
extends into the neighboring organs and tissues, especially into the 
trachea, bronchi, spinal canal, pleura, pericardium, and peritoneum. 
The bronchial glands are frequently infiltrated, and the disease may 
extend into the large arteries in the vicinity. The cancerous growth 
may compress or displace the recurrent laryngeal, especially the left, 
and the pneumogastric nerves. Secondary nodules at times are found 
in the brain, lungs, pancreas, liver, kidney, and adrenal glands. 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 813 

As the growth extends towards the surface of the oesophagus it pro- 
jects in the form of granules, papillary excrescences, or nodules. The 
central older portions become necrotic, are detached, and leave an irregu- 
lar ulcer, which extends superficially and in depth, its edges often being 
everted. Particles of food frequently lodge in the crevices at the bottom 
of the ulcer, putrefy, and thus act as favoring causes in the extension of 
the ulceration, which eventually may result in perforation of the oesoph- 
agus and in the formation of a fistula between the trachea and a bronchus, 
usually the left. Since the tendency of the disease is towards the pro- 
duction of a stricture, that portion of the oesophagus which is above the 
cancer is usually dilated, the muscular coat hypertrophied, and the lining 
membrane in a condition of chronic catarrhal inflammation. 

Symptoms. — Cancer of the oesophagus usually pursues a latent course 
for a long time, and the first symptom of this disease may be a sudden 
and fatal hemorrhage from perforation of a large blood-vessel. As a rule, 
it is announced by difficulty in swallowing solid food, which may increase 
so rapidly as to necessitate within a short time a liquid diet. The greater 
the difficulty in swallowing the more likely is the regurgitation of mate- 
rials swallowed, either unaltered in appearance or mixed with bloody 
slime or frothy fluid. The distress may be so great as to compel the 
patient to refrain from eating, and to lead to the symptoms of starvation. 
Periods of temporary relief to the dysphagia occasionally arise in conse- 
quence of the necrosis and detachment of projecting portions of the cancer 
producing the obstruction. The seat of the discomfort and obstruction is 
usually referred to the back of the neck, the interscapular, substernal, or 
epigastric region. Progressive loss of flesh and strength accompanies the 
dysphagia. 

In the further progress of the disease, other symptoms arise in virtue 
of its extension to neighboring parts and the influence of putrefactive 
conditions in the cancerous ulcer. Pain is often but little complained of, 
although it is severe, constant, or paroxysmal when the intercostal nerves, 
the pericardium, or the pleurae are involved. Cough is frequent from 
the extension of the disease to the larynx, or from perforation of the 
larynx, trachea, or bronchi. It is usually distressing, is either paroxys- 
mal or constant, and is sometimes accompanied with profuse secretion. 
If food enters the lung, broncho -pneumonia rapidly follows. If the re- 
current laryngeal nerve is involved in the growth, aphonia is the result, 
and a rapid, irregular action of the heart follows irritation of the pneu- 
mogastric nerve. When the growth enters the spinal canal, paralysis 
may result from pressure upon the spinal cord. Bleeding from the 
month follows injury to the smaller blood-vessels, while immediately 
fatal hemorrhage is the result of perforation of the aorta or of its larger 
branches. The symptoms of septicaemia or of septico-pyaemia complicate 
and accelerate the progress of cancer of the oesophagus when broncho- 
pneumonia, pleurisy, pericarditis, or peritonitis occurs. The broncho- 



814 



DISEASES OF THE DIGESTIVE APPARATUS. 



pneumonia becomes gangrenous, and perforation into the pleural cavity 
leads to an ichorous pleurisy. The complicating pericarditis and perito- 
nitis are likely to be rather serous or fibrino-serous, perhaps hemorrhagic, 
than ichorous or putrid. Death usually results gradually from starvation, 
rapidly from one of the causes producing septicaemia, or suddenly from the 
erosion of a large blood-vessel. 

Diagnosis. — The recognition of the obstruction of the oesophagus is 
easy from the dysphagia, the delay in the production of the second 
oesophageal murmur, and the use of the sound. The cancerous nature of 
the obstruction is to be inferred from the age and sex of the patient and 
from the appreciation of the fact that ninety per cent, of the cases of 
oesophageal obstruction after middle life are due to cancer. This diag- 
nosis is supported by the recognition of a palpable tumor in the neck, 
from the limitation of the disease to the cervical portion of the oesophagus, 
or from an infiltration of the cervical glands. It is rendered certain by 
the microscopical examination of portions of the cancer which have been 
regurgitated or removed with the oesophageal tube. The possibility that 
syphilis may be a cause of the obstruction is to be remembered, and should 
be eliminated by active anti syphilitic treatment if necessary, unless a 
positive diagnosis of cancer can be made by the examination of portions 
of the growth ejected. 

Prognosis. — Cancer of the oesophagus proves fatal usually within ten 
to fifteen months after the beginning of the symptoms. The prognosis 
in the individual case varies within wide limits, owing to the inability to 
anticipate the occurrence of hemorrhage or of perforation into the respi- 
ratory tract or into the serous cavities. In these events death is likely 
to occur either immediately or in the course of a few days or weeks. 

Treatment. — In the treatment of cancer of the oesophagus the indi- 
cations are to relieve pain and nourish the patient. When solid food can 
no longer be swallowed, milk, eggs, gruels, broths, purees, may be taken 
in large quantities at long intervals, or in small quantities at short in- 
tervals, as seems best to suit the individual. When the power of swallow- 
ing is almost gone, the oesophageal tube may be used. The oesophagus 
above the stricture should be occasionally washed out by the swallowing 
and regurgitation of a weak solution of boric acid. Just before the 
oesophageal tube is to be passed the subject should swallow a small piece 
of frozen solution of cocaine, which may readily be made by means of 
the ethyl chloride spray. Eapid dilatation of the stricture by graduated 
sounds or laminaria tents does not seem to us to be a good practice, be- 
cause it involves the danger of rupture. Authorities recommend carry- 
ing by means of the sound canulas (funnel-shaped above) into the stricture 
and leaving them there. Surgical interference when the stricture is low 
down is of very doubtful utility,- the results of oesophagostomy or gas- 
trostomy so far not having been good. When the cancer is in the upper 
part of the oesophagus, extirpation is practicable. 



DISEASES OF THE MOUTH, TONGUE, SALIVARY GLANDS, ETC. 815 



SPASM OF THE OESOPHAGUS. CESOPHAGISMUS. 

A localized spasm of the muscular coat of the oesophagus occasionally 
takes place, either at the upper or at the lower end of the tube. This 
condition is called oesophagismus, or, from the cause and result, spastic 
stricture or stenosis. The condition is closely allied to the globus hys- 
tericus of the pharynx, and is seen for the most part in nervous women 
between the ages of twenty and forty years, although sometimes observed 
in old age and in childhood. Those suffering from overwork, mental 
shock, or chronic disease, especially of the pelvic organs, are more likely 
to be affected, and English writers consider that gout is a predisposing 
cause. Its occurrence has been observed during the period of gestation. 
It may be a symptom of organic disease of the oesophagus, as inflamma- 
tion, ulcer, or cancer, and also of the central nervous system, especially 
in the vicinity of the medulla oblongata, as in rabies and meningitis. It 
is sometimes present in chorea, tetanus, and epilepsy. 

The spasm is either slight or severe, temporary or prolonged, occa- 
sional or constant. Its frequency and severity usually increase in the 
course of time and become constant, although attacks of longer or shorter 
duration may occur with intervals of freedom perhaps for years. The 
efforts of the patient at swallowing cause distress, and the food may be 
violently regurgitated. The spasm is at times accompanied by hoarse- 
ness of the voice, difficulty of breathing, and hiccough. Hyperesthesia 
of the pharynx is not infrequently associated, and may so act upon the 
oesophagus that, as in rabies, the mere presence of saliva induces the 
spasm, and even the thought of swallowing may bring on a paroxysm. 
Pain varying in character, and a feeling of constriction, usually referred 
to the sternum, the spine, or the shoulders, not infrequently accompany 
the spasm, and a sense of oesophageal fatigue referred to the same regions 
at times follows the more severe spasms. 

The spastic nature of the obstruction is to be inferred from the inter- 
mitting, irregular course of the affection in women of nervous tempera- 
ment, and an organic cause for the obstruction is excluded by the passage 
of the sound. Despite the obvious discomfort, the nutrition of the patient 
is, as a rule, well maintained. If the spasms are continued for a period 
of years, dilatation of the oesophagus may result, and chronic oesophagitis, 
perhaps ending in a fibrous stricture, occur. 

The treatment of oesophagismus is that for spasmodic stricture of the 
oesophagus (page 806). 

PARALYSIS OF THE OESOPHAGUS. 

The oesophagus may become paralyzed in consequence of lesions of 
the central and peripheral nervous system, and in rare instances from 
hysteria. A central origin for the paralysis is to be found in intra cranial 
tumors, hemorrhage, softening, or sclerosis, especially near the medulla 



816 



DISEASES OF THE DIGESTIVE APPARATUS. 



and the pons. Central causes are to be found also in multiple sclerosis, 
tabes, chronic poliomyelitis, and general paralysis. Affections of the 
peripheral nerves are causes for the paralysis in diphtheria and in poison- 
ing from lead or alcohol. (Esophageal paralysis may result from com- 
pression of the pneumogastric nerve by tuberculous or syphilitic disease 
of the adjoining lymph-glands and the vertebrae. 

The paralysis is manifested by difficulty in swallowing, of sudden 
occurrence or of slowly increasing severity. Solid food in large pieces 
is more readily swallowed than liquid food or small fragments. If the 
passage downward of the first mouthful is prevented, the swallowing 
of more food may overcome the stoppage, and if liquids are taken to 
overcome the obstruction regurgitation is likely to follow. The paralysis 
causes a delay in the production of the second oesophageal murmur, and 
a sound or tube passes freely, but the tip does not move about as readily 
as is the case when the oesophagus is dilated, which latter condition is 
somewhat simulated by paralysis of the oesophagus. Since paralysis of 
the oesophagus is the result of a variety of lesions of greater or less 
severity, the prognosis depends upon that of the exciting cause. In 
toxic paralysis, whether from diphtheria, lead, or alcohol, the prognosis 
is favorable, as is the case also in hysterical paralysis, whereas this 
symptom is of grave importance in disease of the central nervous system. 

Treatment. — The treatment of paralysis of the oesophagus is the 
treatment of its cause. If the patient is unable to swallow, feeding by 
the stomach-tube will sustain life. 



DISEASES OF THE STOMACH. 



817 



CHAPTER II. 

DISEASES OF THE STOMACH. 
METHODS OF PHYSICAL EXAMINATION. 

In the determination of the nature of the various diseases of the 
stomach it is of importance to know the position and size of this organ, 
the nature of its contents, the degree of its motility, and its power of 
absorption. These attributes are to be recognized by means of inspection, 
palpation, percussion, auscultation, the chemical and microscopical exam- 
ination of the contents, and the use of certain drugs. 

Inspection of the epigastrium may disclose the size, shape, and position 
of the stomach, especially when inflated with air or gas, preferably by the 
former, since its supply is under more immediate control. For the pur- 
pose of inflation the stomach-tube or an effervescing powder is to be intro- 
duced. The directions to be followed in the use of the tube and the pre- 
cautions necessary are given in the article on the oesophagus, page 805. 
When the tip of the tube is in the stomach, air is readily forced through 
it by means of a bulb syringe connected with the end of the tube. In 
giving the effervescing powder one teaspoonful of tartaric acid is dis- 
solved in a half-tumblerrul of water and swallowed. Immediately after- 
wards one teaspoonful of sodium bicarbonate also dissolved in a half- 
tumblerful of water is to be taken, and the patient cautioned not to 
permit the gas which is formed to escape from the mouth. The pro- 
gressing distention of the stomach is usually visible to the eye as a 
circumscribed bulging of the abdominal wall, either in the epigastrium or 
in the umbilical region or in both, according to the position of the stomach. 
An hour-glass shape has also thus been determined. In rare instances, in 
consequence of pyloric insufficiency, the air or gas passes from the stom- 
ach into the intestine, as may be observed from the resulting change of 
shape of the abdominal wall. Tumors of the stomach also are to be rec- 
ognized at times on inspection, especially when near the pylorus, and, 
although moving but little with the descent of the diaphragm, are fre- 
quently displaced with the pylorus to distant parts of the abdomen. 
Inspection also reveals peristalsis, especially when exaggerated, in conse- 
quence of neurosis or from hypertrophy and dilatation of the stomach 
due to stricture of the pylorus. The wave usually extends from the left 
to the right, but sometimes in the reverse direction, and peristalsis is 
often to be excited by tapping upon the epigastrium or by inflation of 
the stomach. 

Rosenheim has successfully inspected the interior of the stomach by 
means of the gastroscope, which is essentially an enlarged cesophago- 

52 



818 



DISEASES OF THE DIGESTIVE APPARATUS. 



scope. Its use, however, is inconvenient, requires experience, and adds 
but little to the information to be obtained by other means of investiga- 
tion. Mention may be made also of the inspection of the illuminated 
stomach, gastrodiapliany. It is stated that by this method of examination 
the lower border of the normal empty stomach is to be found at the level 
of the navel considerably below the point at which its presence is to be 
determined by means of percussion. 

Palpation of the region of the stomach is best performed when the 
patient lies on the back, with the head low and the knees raised. The 
pressure should be gentle, and made with the finger-tips and the ulnar 
edge of the nearly flattened hands. The object of the palpation is to 
obtain evidence of the size and position of the stomach, to recognize 
points of tenderness and localized resistance. Under normal circum- 
stances only a small part of the stomach near the pylorus and in the 
vicinity of the greater curvature is perceived by the fingers, and then 
only when distended. The pylorus is sometimes to be felt as a circum- 
scribed movable resistance at the right of the median line and on a level 
with the anterior end of the eighth costal cartilage. The lower border 
of the stomach is at times to be differentiated by the touch from the 
transverse colon, in part from the variation in the tension and in part 
from the resistance of the omentum. Tenderness is frequent in disease 
of the stomach, and is often the result of a circumscribed peritonitis, 
whether acute or chronic. This perigastritis is diffused or circumscribed, 
the latter being due often to the presence of ulcer of the stomach. 

The possibility of recognizing the resistance of a normal pylorus has 
been already mentioned. The hypertrophied pylorus is more readily ap- 
preciated, and tumors in this part of the stomach frequently are felt. 
Important evidence is often to be obtained by palpation of the stomach 
under various conditions of distention, either by air, gas, or food. 

Percussion is a most important means of determining the position and 
size of the stomach, especially by making evident the situation of the 
lower edge, and it may aid also in defining the position of a tumor of the 
wall. It is to be done when the stomach is empty, and when distended 
with air, gas, or other contents. A comparison is to be made also between 
the results to be obtained in the upright and those to be obtained in the 
supine position of the patient. Although in general the contrast between 
the stomach and the transverse colon is appreciable on slight percussion 
in consequence of difference in pitch, in cases of especial importance this 
difference may be emphasized by the distention of the one viscus with air 
and of the other with water before the outlines are percussed. According 
to Pacanowsky, the normal upper border of the stomach is near the fifth 
intercostal space in front and at the level of the seventh or eighth rib 
in the axillary region. The lower border may be found three centi- 
metres above the navel. The vertical diameter is from ten to fourteen 
centimetres, and is longer in men than in women. By marking on the 



DISEASES OF THE STOMACH. 



819 



skin the limits of resonance the position of the vertical dilated or pro- 
lapsed stomach may be graphically shown. 

Percussion may aid in determining the position of a tumor, the dulness 
from which will disappear on inflation of the stomach if the growth is 
from the posterior wall. 

Auscultation is of chief importance in the recognition of splashing due 
to the presence of a mixture of air or gas and fluid, and produced by 
quickly tapping upon or by shaking the epigastric region. The splashing 
is often caused by a voluntary contraction of the abdominal muscles by 
the patient. This sound may occur normally after eating, but if present 
immediately before meals is evidence of retention of the contents of the 
stomach either from atony of the wall or from stricture of the pylorus. 
If the splashing is heard over an unusually wide area it offers evidence 
of dilatation, although it may be heard below the navel when there is 
simply prolapse of the stomach. 

A gurgle originating in the stomach is due to the motion of air or gas 
alone, and is of no pathological significance. It is stated that a sound 
resembling that from a freshly opened bottle of liquid charged with car- 
bonic acid gas may proceed from a dilated stomach in consequence of 
fermentation of its contents. The heart-sounds are to be heard distinctly 
on listening over a stomach distended with air or gas, and present a clear 
metallic character. 

Examination of the Contents of the Stomach. — Important 
evidence of the condition of the stomach, especially with reference to 
modifications of its digestive power and its motor activity, is to be ob- 
tained by the examination of the contents. More accurate and com- 
plete knowledge is to be obtained when the contents are siphoned or 
expressed from the stomach through the tube at a definite time after a 
test meal has been taken, than from an examination of the vomitus. 
The meal recommended by Ewald and Boas consists of three or four 
hundred grammes of weak tea or water and thirty to forty grammes of 
white bread, practically a glass of the liquid and a roll of bread. The 
contents of the stomach are to be removed about an hour after this 
meal has been taken. That recommended by Leube and Eiegel requires 
a longer time for digestion, and is to be removed four or five hours 
after being eaten. It consists of four hundred grammes of soup, one 
hundred and fifty to two hundred grammes of beefsteak, and fifty 
grammes of white bread or of mashed potato, essentially a plate of soup, 
a piece of steak, and a roll of bread. 

The contents of the stomach may be altered in quantity and quality. 
If more is removed than is introduced it is evident that there is retention 
from pyloric obstruction or enfeebled motor power of the stomach, and if 
several pints are expressed or siphoned out the stomach must be dilated. 

Variations in quality comprise abnormal odor, color, consistency, and 
chemical and microscopical characteristics. "When the odor is suggestive 



820 



DISEASES OF THE DIGESTIVE APPARATUS. 



of the presence of an acid, fermentation has probably taken place, as in 
the enfeebled or dilated stomach. If the odor resembles that of vinegar, 
it is dne to acetic acid ; if that of rancid butter, the presence of butyric 
or volatile fat acids is indicated. To distinguish between the two by 
chemical means is of no practical importance. A faecal odor is present 
when there are an incompetent pylorus and a complete and prolonged 
obstruction of the bowels. 

The expressed contents of the stomach are usually colorless, but may 
be green from the presence of bile, or red or black from that of blood. 
The consistency is homogeneous, or particles of undigested food, indica- 
tive of retarded digestion, are present. Abundant mucus occurs in 
catarrhal gastritis, and a frothy scum is due to fermentation, which exists 
only when there is retention of the contents. 

The chemical examination of the siphoned or expressed contents after 
a test meal relates to the presence of acidity, which is caused by free 
hydrochloric acid, fixed hydrochloric acid, and acid salts or organic acids, 
to the presence of pepsin and other digestive ferments, and to the products 
of digestion, especially peptones. The chemical examination alone of 
the contents of the stomach is insufficient for an exact diagnosis. It 
represents merely one source of evidence, and its results are of value 
rather as affording indications for treatment than as characterizing the 
nature of the disturbance. Of greatest practical importance is the 
recognition of free hydrochloric acid and of lactic acid, and the abundant 
presence of the former excludes any considerable degree of abnormal 
fermentation, which is the source of the latter. 

The reagent commonly employed for the recognition of free acid is 
Congo paper, which is prepared by soaking absorbent paper in a watery 
solution of Congo red, one of the coal-tar colors. The red paper when 
dipped in the gastric contents becomes blue from the presence of free 
acids, usually free hydrochloric acid, since lactic acid, according to 
Eiegel, is unlikely to be found in sufficient quantity to cause the change 
in color. The test for free hydrochloric acid is that of Gunzburg, and 
consists of two parts of phloroglucin, one part of vanillin, and thirty 
parts of absolute alcohol. The mixture is to be freshly prepared from 
time to time and kept in a dark- colored bottle. A few drops of the re- 
agent are to be added to the same amount of filtered gastric contents 
spread on a porcelain dish, and the mixture is to be heated slowly over 
a small flame. As the fluid evaporates, a red color is formed if free 
hydrochloric acid is present, and the experienced eye is able usually to 
detect an increase or a diminution from the shade and amount of color. 
The absence of free hydrochloric acid is indicative of a deficiency of 
the digestive power of the gastric juice ; its persistent absence is the 
rule in cancer of the stomach and in atrophic or degenerative conditions 
of the mucous membrane. The quantitative estimation of the total gas- 
tric acidity is made by dropping from a burette a decinormal solution of 



DISEASES OF THE STOMACH. 



821 



soda into ten cubic centimetres of filtered gastric contents to which three 
or four drops of a one per cent, alcoholic solution of phenolphthalein 
have been added. When the mixture, which is to be stirred constantly, 
is rendered alkaline, it assumes a homogeneous red color. The degree 
of total acidity is measured by the quantity of the soda solution re- 
quired to render the gastric contents alkaline. Each cubic centimetre of 
the sodic hydrate necessary for this purpose corresponds to 0.003646 
gramme of free hydrochloric acid. Normally from 4 to 6.5 cubic centi- 
metres are used, representing a total acidity of 0.145 to 0.236, or for 100 
cubic centimetres a percentage of 0.145 to 0.236. It is of no practical 
importance, however, to determine quantitatively the total acidity, since 
the digestive power of the gastric juice is dependent upon the presence 
of free hydrochloric acid. 

The recognition of lactic acid is important, since this substance 
normally does not occur in appreciable quantities in the stomach unless 
it is a constituent of the food. When present it is the result of fermenta- 
tion in the contents of the stomach, retained either from mechanical 
obstruction or from diminished motor activity. To avoid the introduc- 
tion of lactic acid in the food, Boas recommends that before applying the 
test the stomach should be washed by means of the tube. A gruel made by 
the addition of a teaspoonful of oatmeal to a quart of water and flavored 
with salt- is then to be taken, and an hour later the contents of the stomach 
are to be removed and tested for lactic acid. According to Rosenheim, 
however, there is not sufficient lactic acid in Ewald's test breakfast to 
form a source of error by giving a positive reaction by the test ordinarily 
used. The presence of lactic acid is to be determined by Uffelmann's 
test, which, although rough, is sufficient for practical purposes. Ten 
cubic centimetres of a four per cent, solution of carbolic acid are to be 
diluted with twenty cubic centimetres of distilled water, and one or two 
drops of the official liquor ferri chloridi are to be added, when a clear 
blue fluid is formed. The production of a greenish- yellow color when 
this is mixed with the filtered gastric contents indicates the presence of 
lactic acid. Eiegel states that a like result follows the use of the fluid 
prepared by the addition of distilled water to a few drops of the ferric 
chloride solution until the latter is nearly colorless. The addition of a 
few drops of a two per cent, to four per cent, solution of carbolic acid 
will produce a blue-colored reagent, which is to be freshly prepared when- 
ever used. The frequent presence of lactic acid in cancer of the stomach 
even before the appearance of a tumor is noteworthy. Boas found it 
present in twenty out of twenty- one cases of cancer, and Klemperer in 
twelve out of fifteen cases. Rosenheim found lactic acid present in 
seventy-eight per cent, of the cases of cancer of the stomach examined 
by him. In about one- fourth of the cases it appeared only at a late stage 
in the disease. The eventual presence, therefore, of lactic acid in the 
contents of the stomach is an important sign of this disease. It is not 



822 



DISEASES OF THE DIGESTIVE APPARATUS. 



infallible, however, since cancer may occur when lactic acid is absent, and 
lactic acid may be present in the contents of the non- cancerous stomach. 
Indeed, Rosenheim has found free hydrochloric acid, even superacidity, 
in twenty-seven per cent, of forty-seven cases of cancer examined. 

The digestive power of the gastric juice may be directly tested by the 
addition of a small piece of the white of a hard-boiled egg to the filtered 
gastric contents and keeping them at the temperature of the body. If 
the gastric juice is normal, the egg albumen disappears in the course of 
an hour and a half. If free hydrochloric acid is absent, pepsin is usually 
present, although the albumen remains undissolved, in which case a few 
drops of the acid should be added to the contents of a second tube and the 
trial again made. If the albumen remains undissolved, a deficiency of 
pepsin is indicated. 

If further inquiry is desired, the presence of peptones may be deter- 
mined by the biuret reaction, — that of starch by the blue color and that 
of dextrine by the red color following the addition of iodine. 

The absorptive power of the stomach may be shown by means of 
potassium iodide, two grains of which enclosed in a thin gelatin capsule 
are to be swallowed. Normally the iodine can be recognized in the 
saliva by means of the starch test fifteen minutes after its ingestion. 

The motile power of the stomach may be determined when there is no 
stricture of the pylorus by means of salol, which is normally decomposed 
and absorbed in the intestine an hour after it has been swallowed in a 
gelatin capsule. The time of its absorption is shown by the appearance 
of salicyluric acid in the urine, as indicated by the production of a violet 
color on the addition of a few drops of a neutral solution of ferric chlo- 
ride. If this reaction is delayed for several hours, or persists after twenty- 
four hours, motor insufficiency is indicated. 

The evidence to be obtained from the microscopical examination of 
the contents of the stomach relates to the presence of numerous undi- 
gested muscle-fibres as a sign of defective digestive power, of blood- 
corpuscles or blood-pigment as a suggestion or confirmation of the exist- 
ence of ulcer or of cancer, and of sarcina or ferment fungus in proof of 
fermentation of the contents of the stomach. 

MALPOSITION OF THE STOMACH. 

The normal position of the stomach in the foetus is distinctly vertical. 
This position is sometimes found in the adult, and the pyloric end of the 
stomach may lie below the navel, as the result of the persistence of the 
congenital condition, or in consequence of the application of pressure, as 
from corsets. The irregularity is of no clinical importance unless it 
causes the duodenum to become angular, in which case dilatation of the 
stomach from obstruction to the passage of its contents results. In rare 
cases the stomach is to be found in the right hypochondrium, the cardiac 
end being at the right and the pylorus at the left of the organ. 



DISEASES OF THE STOMACH. 



823 



Most important of the malpositions of the stomach is gastroptosis, the 
downward displacement. When it exists the smaller curvature of the 
stomach may be midway between the ensiform cartilage and the navel, 
while the greater curvature lies between the navel and the symphysis 
pubis. This prolapse of the stomach is dependent upon elongation of 
the gastrohepatic omentum, either existing at birth or in consequence of 
traction, muscular strain, or injury. A lax condition of the abdominal 
wall in consequence of repeated pregnancies and lacing acts as a favoring 
cause. Prolapse of the stomach occurs oftener in women than in men, 
and is usually associated with prolapse of other abdominal organs, espe- 
cially the kidney. The displaced stomach may be of normal size, but 
is frequently dilated. The functional activity of the stomach may be 
normal, but is usually altered in consequence of atony of the wall or 
because of the disturbances of secretion to be found in gastric neurosis. 
Owing to these variations in the condition of the stomach, the prolapsus 
may give rise to no symptoms, or the complex disturbances found in 
gastric atony, dilatation of the stomach, and nervous dyspepsia may be 
present. The diagnosis is to be made by the examination of the inflated 
stomach, the percussion of which gives evidence of its position. The 
prolapsed is to be distinguished from the dilated stomach by the fact that 
both the upper and the lower borders are displaced downward. Atony 
of the wall of the prolapsed stomach is indicated by splashiug on succus- 
sion in addition to the presence of symptoms dependent upon the reten- 
tion of the gastric contents. The symptoms attributable to the prolapsed 
stomach are relieved by the treatment appropriate for nervous dyspepsia, 
and the prognosis of the two affections is essentially the same. 

DILATATION OF THE STOMACH. GASTRECTASIS. 

Definition. — Increase in the capacity of the stomach from enlarge- 
ment of its cavity. 

Etiology. — Dilatation of the stomach occurs at all ages, more com- 
monly in adults, and in both sexes. It is the result of interference with 
the passage of its contents into the intestine, from their increased bulk, 
from mechanical obstruction, or from weakness of the wall. Overloading 
of the stomach occurs in gluttons and in the insane, and from the exces- 
sive drinking of beer or of water. Obstruction is usually at or near the 
pylorus, and may exist at birth as a congenital stenosis, or as an angular 
bend of the duodenum from a vertical stomach. Acquired obstruction is 
usually the result of a scar from chronic ulcer of the stomach or duodenum 
or from corrosive poisons. Tumors of the pylorus, either cancer or local- 
ized hypertrophy, and frequently recurring spasmodic contraction of the 
pylorus, are also regarded as causes of obstruction. Tumors compressing 
the pylorus or the duodenum, or dragging upon the latter, or perhaps 
the floating kidney, are of importance in etiology, and the compression 
may be occasioned by fibrous bands or scars from a localized peritonitis. 



824 



DISEASES OF THE DIGESTIVE APPARATUS. 



Weakness of the wall may be the result of chronic inflammatory 
changes extending to the muscular coat from the mucous membrane in 
gastric catarrh, or from the peritoneum in perigastritis. Degenerative 
changes in the muscular coat in acute or chronic disease also act as 
causes of weakness or enfeeblement, and atony of the muscular coat is 
considered to exist where there is dilatation without evidence of organic 
disease. 

Dilatation is either acute or chronic in accordance with the temporary 
or the continuous action of the cause. Acute dilatation is rare, but the 
stomach may be largely dilated from paresis of the wall in the course of a 
day or two after the occurrence of acute intestinal obstruction or general 
peritonitis. 

Morbid Anatomy. — The stomach may be so distended as to fill the 
entire front of the abdomen, the greater curvature lying at the brim of 
the pelvis, and its capacity may be increased from the normal three pints 
to thirty pints. In acute dilatation the wall is stretched and thin ; in 
chronic dilatation, especially from pyloric obstruction, compensatory 
hypertrophy may exist for a long time, and the wall of the stomach be 
found thickened. In chronic dilatation the mucous membrane usually 
presents the changes characteristic of chronic gastritis, and degenerative 
changes are likely to be found in the muscular coat. 

Symptoms. — The appetite varies, but is usually feeble. There is fre 
orient belching of odorless or offensive gas. Pyrosis may occur soon after 
eating, or take place several hours after food has been taken. The hot 
fluid regurgitated immediately after eating is irritating in consequence 
of the presence of acids from fermentation, while the acridity of that 
regurgitated later in the digestive process is often attributable to free 
hydrochloric acid. There is a sensation of fulness or distress in the epi- 
gastrium even after eating but little food, and nausea and vomiting are of 
frequent occurrence. Large quantities, perhaps three or four quarts, 
may be vomited even before breakfast, and may contain particles of undi- 
gested food, especially the skins and seeds of fruit eaten days or weeks 
previously. The salol test will show impaired motility, and the use of 
potassium iodide will indicate defective absorption. If the vomit is kept 
for a while in a suitable receptacle, a frothy layer forms on the surface, 
below which is a thin grayish-brown fluid, and at the bottom are par- 
ticles of undigested food. Bubbles of gas are at times to be seen rising 
from the bottom of the dish. 

In consequence of the prolonged retention and deficient absorption of 
the contents of the stomach, the bowels are constipated, the urine is scanty, 
and there is marked thirst. The general nutrition is usually lessened, 
the skin is dry and rough, and there may be extreme emaciation. Dis- 
turbances of the nervous system are at times complained of, such as head- 
ache and dizziness. These and the less frequent cramps, delirium, and 
coma are usually attributed to the absorption from the stomach of the 



DISEASES OF THE STOMACH. 



825 



products of the fermentation of its contents. In rare instances tetany has 
been observed, and has proved a cause of death. 

On physical examination the abdomen is found distended either in 
the epigastrium or in the vicinity of the navel, or in both regions, and 
peristalsis is visible during the existence of compensatory hypertrophy, 
especially when the abdomen is palpated. On percussion the area of 
gastric resonance is markedly increased, and a change in the resonant 
area may result from an alteration in position of the patient. The in- 
creased area of resonance is most satisfactorily determined after inflation 
of the previously emptied stomach. On auscultation a splashing sound 
produced by palpation or succussion is to be heard over a wide area. 
The chemical examination of the contents of the stomach, according to 
the cause and persistence of the dilatation, shows every variation in the 
quantity of free hydrochloric acid, but more frequently in the protracted 
cases there is no free hydrochloric acid, but lactic, butyric, or acetic 
acid, carbonic acid gas, hydrogen, sulphuretted hydrogen, and even 
phosphoretted hydrogen, as shown by Ewald, may be present. On mi- 
croscopical examination sarcina and various fungi are to be found. The 
urine is often alkaline, and contains an increase of phosphates. 

Diagnosis. — The increased area of tympany produced by the inflated 
stomach, splashing, and the possibility of removal by the tube from the 
stomach before breakfast of a considerable amount of contents, are char- 
acteristic of dilatation of the stomach. Moderate degrees of dilatation 
are easily confounded with simple atony or atony with prolapse of the 
stomach. In simple atony there may be temporary enlargement of the 
stomach, but the amount of contents is usually relatively normal, and the 
disturbance of nutrition is often inconsiderable. In dilatation enlargement 
of the stomach is permanent, the contents are indicative of fermentation, 
and emaciation is the rule. The upper border of the inflated prolapsed 
stomach lies between the ensiform cartilage and the navel, whilst that of 
the dilated stomach is to be found in the immediate vicinity of the apex 
of the heart. A mechanical cause of the dilatation is suggested by the 
previous history of ulcer, a palpable tumor at the pyloric end of the 
stomach, visible peristalsis, or extreme emaciation. Atony is suggested as 
a cause of dilatation by the previous history of the patient and by the ab- 
sence of physical signs suggestive of a mechanical dilatation. Although 
the dilated stomach has been so large as to indicate an ovarian cyst and 
has been tapped, the use of the stomach- tube would render this operation 
or an exploratory laparotomy unnecessary for diagnosis. 

Prognosis. — The prognosis of dilatation of the stomach is based 
chiefly upon the cause and the duration. It is unfavorable in malignant 
disease, grave in case of fibrous stricture, and favorable when the dilatation 
is the result of atony. The greater the degree of dilatation and the longer 
its persistence the more unfavorable its prognosis, whatever may be the 
ca use, since insuperable atrophy of the mucous membrane may result. The 



826 



DISEASES OF THE DIGESTIVE APPARATUS. 



surgical treatment of dilatation of the stomach, from mechanical causes, 
especially when performed before the dilatation has reached an extreme 
degree, renders the prognosis more favorable in case of fibrous stricture, and 
makes life more endurable and even prolonged in case of cancer. 

Treatment. — The treatment of dilatation of the stomach, apart from 
the removal of the cause, consists in little more than washing out the 
stomach and careful regulation of the diet, — procedures which in many 
cases bring about a good result by relieving the basal catarrhal condition, 
and which when the cause of the dilatation is irremediable do good by 
removal of the fermenting mass of food and secretions which accumulate 
because they cannot escape through the pylorus. 

The introduction of gastric lavage in 1867 by Kussmaul marked an 
era in the treatment of gastric diseases. In washing out the stomach it is 
better to remove the contents by siphonage than by the stomach-pump. 
The apparatus required is very simple, consisting of a long, soft stomach- 
tube or Nelaton's catheter, with sufficiently large side openings near the 
open or closed end, and united above to an india-rubber tube about a 
yard in length and terminating in a large funnel. After the stomach-tube 
has been introduced, the funnel filled with water is raised above the head 
of the patient, and when it has nearly emptied itself is lowered below the 
stomach of the patient, so as to produce a reversal of the current. The 
process is so easy that it is usually better to teach the patient to do it 
himself. At first it may be better to wash out the stomach two or three 
times a day, but when the viscus has once been thoroughly cleansed 
lavage should be usually practised only once a day, preferably at a time 
distant from a meal, as in the early morning or in the late evening. 
Pure water of about 100° F. may be commonly used ; but when there is 
much fermentation a two per cent, solution of boric acid, or a one per 
cent, solution of salicylic acid or of resorcin, may be employed. 

The feeding of a case of dilatation of the stomach should be that of 
severe chronic gastric catarrh, the food consisting chiefly or entirely of 
scraped beef, predigested foods, or cooked meat, which should always be 
very tender and thoroughly masticated. Milk diet also may be tried. 
It should be given at short intervals. 

The power of contracting the muscular coat of the stomach has been as- 
signed by various practitioners to certain remedies, notably strychnine and 
electricity. The alkaloid may be freely administered internally and the fara- 
dic current used locally, though the effect is probably very slight. When the 
dilatation is pronounced an elastic abdominal bandage is often serviceable. 

For the treatment of pyloric stenosis three surgical procedures are 
in vogue. Loreta's operation consists in digital dilatation after gas- 
trotomy ; it is applicable only to non-malignant cases ; according to 
Schroeter, it had up to 1894 a mortality- rate of about forty-six per cent. 
Moreover, in the greater proportion of successful cases there has been 
a recurrence of the stenosis. 



DISEASES OF THE STOMACH. 



827 



Gastro- enterostomy consists in making an opening between the stomach 
and the intestines and uniting the two. According to Magill, in sixty- 
one gastro -enterostomies, made by the aid of plates or other mechanical 
devices (not sutures) between 1887 and 1894, the gross mortality was about 
twenty-three per cent. ; the mortality with sutures seems to have been 
about fifty per cent. 

According to Dreydorff, the mortality of pylorectomies up to 1894 was 
about seventy-five per cent. ; but an improving technique seems to be 
reducing this greatly, as in nine cases Kocher had only two deaths. (See 
also Prognosis.) 

GASTRITIS. 

Definition. — Inflammation of the stomach. 

Inflammation of the stomach usually results from a local irritation of 
its mucous membrane, and the resulting changes are both superficial and 
deep-seated, affecting the epithelium of the surface, the glands, and the 
interstitial tissue. In severe cases the inflammatory process extends to- 
wards the peritoneal coat of the stomach, which it sooner or later reaches, 
the intervening structures being involved to a greater or less extent. The 
distinction of clinical convenience is that between acute and chronic gas- 
tritis. Acute gastritis is either catarrhal, pseudo- membranous, or phleg- 
monous according to the anatomical changes, or toxic, mycotic, or parasitic 
according to the conspicuous features in etiology. Chronic gastritis is 
largely catarrhal, but is sometimes associated with proliferation or atrophy 
of the mucous membrane, and at other times with sclerosis of the wall of 
the stomach. 

ACUTE CATARRHAL GASTRITIS. ACUTE GASTRIC CATARRH. 
ACUTE DYSPEPSIA. 

Etiology. —Local irritation from food or drink is the usual exciting 
cause of acute catarrhal gastritis. The contents of the stomach when 
swallowed may be too hot or too cold, improperly prepared, or excessive in 
quantity. Of especial importance are fermented or decomposed food, as 
putrid meat or fish, sour milk, unripe or rotten fruit, ill- kept fermented 
liquors, and alcoholic excess. The bacterial infection of the food or drink 
is of especial importance, and epidemics of infectious gastritis have been 
reported in which a number of persons have simultaneously suffered from 
partaking in common of infected food or drink. Such instances of infec- 
tious gastritis are not to be confounded with the usual occurrence of acute 
gastritis in acute infectious diseases. 

Predisposing causes are also important, since all exposed to the same 
exciting cause do not alike suffer. A vulnerable condition of the stom- 
ach prevails in certain families, and may be inherited. It is especially 
frequent among brunettes, so often characterized as bilious, in the very 
old, and in the very young, and may also result from bad hygienic sur- 
roundings and acute or chronic disease. 



828 



DISEASES OF THE DIGESTIVE APPARATUS. 



Morbid Anatomy. —The appearances of the mucous membrane of 
the stomach in acute catarrhal gastritis are rarely observed, since the 
disease is rapidly recovered from. Our knowledge of them is based 
chiefly upon the direct observation by Beaumont of St. Martin's stomach, 
and is confirmed in rare cases of death from other causes during an acute 
catarrhal gastritis and by experiment. The mucous membrane is swollen, 
red, and either dry or covered with abundant viscid mucus. Minute 
hemorrhages may be observed, and superficial erosions are to be seen, 
especially along the projecting folds of the contracted stomach. Micro- 
scopical examination shows a granular condition of the glandular epithe- 
lium, sometimes associated with a cellular infiltration of the interstitial 
tissue. When the glands are decidedly swollen and granular the mucous 
membrane of the stomach is opaque gray, especially at the pyloric end, 
and the condition has been designated parenchymatous gastro-adenitis. 

Symptoms. — The symptoms vary in accordance with the mildness or 
the severity of the attack. There is a loss of appetite, or a desire for 
pungent, sour, saline, very hot or ice-cold articles of food or drink. 
Thirst is usually conspicuous, although the patient may be loath to 
swallow through fear of vomiting, and there is an unpleasant taste in 
the mouth. Nausea, belching, and vomiting are more or less constant, 
and hiccough is occasional. The regurgitation of a tasteless fluid, water- 
brash , or of an acrid, burning fluid, pyrosis, is frequent. There is more 
or less discomfort, sometimes intense pain, in the epigastric region, to 
which a faint, " all- gone" feeling is often referred, and constipation is 
the rule, but is sometimes followed by diarrhoea. 

The patient complains of headache, is dull and sleepy or fretful, espe- 
cially if a child, and in the infant delirium or convulsions may occur, sug- 
gesting a meningitis. In the mild cases there is little or no elevation of 
temperature, but in the severe cases the temperature may rise to 101° or 
102° F., and the beginning of the attack be announced by a chill. The 
tongue is usually covered by a white coat, and the breath is offensive from 
the associated catarrhal stomatitis. Herpes of the lips is occasionally ob- 
served. The epigastrium is often distended, tympanitic, and tender. The 
vomit consists at first of undigested food, which may have been retained 
for many hours. With the persistence of the vomiting the contents of 
the stomach are either alkaline from deficient hydrochloric acid and 
abundant alkaline mucus, or acid from the presence of lactic acid or 
butyric acid in consequence of fermentation, or bitter from peptones or 
bile. The urine is scanty and high-colored. 

The causes of a gastritis are often those of a gastro -enteritis, and the 
association of jaundice with the above-mentioned symptoms of catarrhal 
gastritis is indicative of extension of the inflammation to the duodenum. 
This gastro-duodenal catarrh is the usual cause of acute jaundice, bilious 
attacks, or " acute hepatic torpor." It is also to be remembered that 
acute pancreatitis is frequently preceded by the symptoms of a gastro- 



DISEASES OF THE STOMACH. 



829 



duodenitis. The advance of the irritant, perhaps a specific bacterium, to 
the ileum is manifested by profuse diarrhoea, which, combined with 
gastric symptoms and collapse, is significant of cholera, cholera nostras, 
or poisoning by putrid meat, fish, or milk products. 

Diagnosis. — Mild cases of acute catarrhal gastritis are readily diag- 
nosticated from the immediate occurrence of the symptoms after indiges- 
tible food or other irritants have been taken into the stomach. The 
diagnosis becomes difficult in acute febrile gastritis of obscure etiology, 
since the condition may be due to the invasion of an acute infectious dis- 
ease. The absence of characteristic symptoms in the course of a few days 
serves to eliminate the exanthemata. The early symptoms of typhoid 
fever often resemble those of acute catarrhal gastritis, but in the course 
of time the typical range of temperature, the enlargement of the spleen, 
the presence of a rash, and the diazo-reaction make clear the existence 
of typhoid fever. 

Prognosis. — Acute catarrhal gastritis is usually a mild affection, last- 
ing from a few days to a fortnight. Bapid recovery often follows the 
vomiting of the irritating cause, or its expulsion from the bowels when 
diarrhoea is a complication. Gastritis complicated with duodenitis may 
last for weeks, and the prognosis of gastro- enteritis is stated in the con- 
sideration of acute enteritis. Frequently recurring attacks of acute 
catarrhal gastritis are likely to result in chronic catarrhal gastritis. 

PSEUDO-MEMBRANOUS GASTRITIS. 

This variety of acute gastritis is characterized by the presence of large 
or small patches of a membrane either loosely applied or intimately ad- 
herent to the mucous membrane of the stomach. The condition is rare, 
and occurs as a complication of severe infectious diseases, especially 
diphtheria, scarlet fever, small-pox, septicaemia, malignant endocarditis, 
and pneumonia. There are no distinctive symptoms unless portions 
of membrane be vomited. 

PHLEGMONOUS GASTRITIS. 

In rare instances a circumscribed or diffuse purulent infiltration of the 
submucous tissue of the stomach occurs. Single or multiple abscesses 
result, the former having been observed as large as the fist, and are dis- 
charged into the stomach or perforate the peritoneal coat. Phlegmonous 
gastritis has been found oftener in men than in women, more frequently 
in drunkards, and occurs without obvious exciting cause, or as a compli- 
cation of ulceration of the stomach or in the course of a septic process, 
as puerperal infection or malignant endocarditis. 

The onset is usually sudden, and is characterized by severe epigastric 
pain, high fever, with morning fall and evening rise of temperature, 
typhoidal symptoms, and eventual coma or collapse. The abscess lias 
been felt as a tumor through the abdominal wall, and pus has appeared 



830 



DISEASES OF THE DIGESTIVE APPARATUS. 



in the vomit and the dejections. The course of phlegmonous gastritis is 
usually acute, though sometimes chronic. The diagnosis rarely has been 
made, and the condition is most to be suspected when the symptoms of 
an acute perigastritis without obvious cause are present. The progno- 
sis is unfavorable, death resulting from an extension of the suppuration 
to the peritoneum with the production of a general peritonitis, or in 
consequence of progressive emaciation and debility from the resulting 
destruction and associated disturbance of function of the mucous mem- 
brane of the stomach. In rare cases healing, with extensive deformity 
of the stomach from scars, may take place. 

TOXIC GASTRITIS. 

This variety of inflammation of the stomach is due to the introduction 
of poisonous chemicals, especially sulphuric, nitric, oxalic, and carbolic 
acids, caustic alkalies, phosphorus, arsenic, antimony, corrosive subli- 
mate, and potassium cyanide. The resulting lesions resemble those 
described in connection with corrosive inflammation of the oesophagus. 
Phosphorus, arsenic, and antimony are likely to produce extensive paren- 
chymatous degeneration of the glands of the stomach. The symptoms 
indicative of the entrance of the poisons into the stomach are localized 
epigastric pain, persistent vomiting of blood, and a swollen and tender 
epigastrium. The effect of acute poisoning from irritants swallowed is 
considered in the chapter on Poisoning, pages 360-362. 

When gastritis is due to the growth of fungi in the stomach, as the 
favus fungus, or to that of anthrax bacillus in the wall, the condition is 
known as a mycotic gastritis. The larvae of certain insects and intestinal 
parasites when present in the stomach may be productive of a gastritis 
to which the term parasitic gastritis has been applied. Further infor- 
mation on this subject is to be found in the chapter on Diseases due to 
Animal Parasites, page 321. 

Treatment. — The treatment of acute gastritis varies with the causa- 
tion. In the simplest cases all that is necessary is to restrict the food 
to milk with lime water and broths, and give a saline purge : such treat- 
ment being preceded by an emetic if the stomach contain undigested food. 
In severe cases it may be necessary to leech, to give aconite with anti- 
pyrin if there be fever, and to purge with a mercurial followed by salines. 

When an acute gastritis is due to an irritant poison, the stomach after 
having been well washed out should be left for twenty-four hours or 
longer, according to the severity of the case, without food ; leeches 
should be placed upon the epigastrium, followed, if necessary, by blis- 
ters ; opium should be given freely, and bismuth subnitrate or subcar- 
bonate carefully administered in small repeated doses. When the acute 
catarrh is the outcome of an alcoholic debauch, the patient should be 
well vomited by ipecacuanha given in five-grain doses repeated every 
ten minutes until the effect is produced, and afterwards should be freely 



DISEASES OF THE STOMACH. 



831 



purged by quarter-grain doses of calomel administered every hour, aided 
by a saline if necessary. The food should be broths, milk, or similar 
bland liquids, in small quantities, or should for the time being be en- 
tirely withheld from the stomach, the patient being sustained by nutri- 
tive enemata. Leeches to the epigastrium are rarely required, but the 
blister is often of great service. The use of stomachic bitters and simi- 
lar irritant substances is strongly contra-indicated in gastric catarrh, 
except that in alcoholic subjects after the first few days hydrastine or 
fluid extract of hydrastine is often a very useful remedy ; and that 
when the so-called acute catarrh of an alcoholic is really an exacerbation 
of a chronic gastritis with great relaxation of the vessels and benumb- 
ing of the gastric nerve-endings, local stimulants, such as tincture of 
Cayenne pepper and compound tincture of gentian, are often of service 
after the first few days of treatment. 

CHRONIC GASTRITIS. CHRONIC CATARRHAL GASTRITIS. CHRONIC 
GASTRIC CATARRH. CHRONIC DYSPEPSIA. 

Etiology. — The prolonged or frequently recurrent action of the 
causes of acute gastritis is an important factor in the etiology of chronic 
gastritis. Prominent among these causes are the long- continued use of 
unsuitable or improperly prepared articles of food, persistently irregu- 
lar or hurried meals, insufficient mastication, and the abuse of tea, coffee, 
tobacco, and especially of alcohol. Chronic gastritis is a frequent ac- 
companiment of cancer and dilatation of the stomach, and is sometimes 
associated with ulcer. It may follow chronic passive congestion of the 
mucous membrane not only from obstruction of the portal circulation, 
but also from chronic affections of the heart and lungs, and is of fre- 
quent occurrence in chronic tuberculosis, nephritis, gout, diabetes, and 
prolonged primary and secondary anaemias. 

Morbid Anatomy. — In simple chronic catarrhal gastritis the mucous 
membrane is swollen, injected, of a bluish slate color from the presence 
of metamorphosed blood-pigment, and is covered with abundant grayish- 
white mucus. These alterations are seen especially in the chronic ca- 
tarrhal gastritis due to passive congestion. The severe forms of chronic 
gastritis are those in which more conspicuous structural changes take 
place in the wall of the stomach. According to the nature and effect of 
these changes a distinction is drawn between hypertrophic or prolifer- 
ating gastritis and atrophic gastritis. In hypertrophic gastritis there 
is a cellular infiltration of the mucous membrane of the stomach asso- 
ciated with enlargement of the glands, which become tortuous and 
even hyperplastic. Polypoid projections of the mucous membrane may 
be formed, and a lobulated or corrugated — the mammillated — condition 
of the surface results, in part from the contraction of the inflamed wall, in 
part from the abnormal growth of the interglandular tissue. The orifices 
of the glands are frequently constricted, causing dilatation of the ducts 



832 



DISEASES OF THE DIGESTIVE APPARATUS. 



and the formation of cysts. The capacity of the stomach may be normal 
or somewhat increased. In atrophic gastritis a shrinkage of the inflamed 
mucons membrane occurs, in consequence of which it becomes thin, 
smooth, and dense, suggestive rather of a thickened serous membrane 
than of a mucous membrane, and an extreme degree of atrophy of the 
glands ensues. Sclerosis or cirrhosis of the stomach is the result of an 
involvement of all the coats of the stomach in the inflammatory pro- 
cess. In consequence of the shrinkage of the fibrous tissue the stomach 
may be so diminished in size as to hold but a few ounces. The wall 
is increased in thickness and in density. The gross appearances 
closely resemble those of fibrous cancer, so-called scirrhus, and a micro- 
scopical examination is often necessary to exclude the existence of this 
disease. 

Symptoms. — The local and general symptoms of chronic catarrhal 
gastritis resemble those of other affections of the stomach, especially 
acute catarrhal gastritis. They are, however, usually of gradual onset, at 
first being only occasional, but eventually are persistent. There is fre- 
quently a disagreeable taste in the mouth, which may be moist or dry, and 
the appetite is feeble, often perverse, and sometimes excessive. There is 
occasional thirst, especially when the mouth is dry, although often there 
is a profuse secretion of saliva. Nausea is frequent both before and after 
eating, and vomiting is of occasional occurrence. In alcoholic gastritis 
the vomiting of mucus before breakfast is conspicuous, and is attributable 
to the retching caused by efforts at clearing the pharynx from the abundant 
adherent secretion. Vomiting also takes place after food has been taken, 
and then consists of incompletely digested particles of food, which may be 
covered with mucus. Belching during and after meals is frequent, the 
gas raised being either odorless or offensive. Eegurgitation of liquid, 
either bitter from the presence of peptones, or acrid from free hydro- 
chloric acid or organic acids from fermentation, is a source of discom- 
fort. The patient complains of a faint, " all-gone" feeling in the epi- 
gastrium before eating, but food usually produces a sensation of fulness, 
of weight, as from a piece of lead, or of tension, demanding relief from 
external pressure. There may be actual pain, sometimes severe, espe- 
cially after eating, referred to the region of the stomach. The bowels 
are usually constipated, and flatulence is frequent. The evacuations 
sometimes contain undigested particles of food. 

The patient complains of headache and of dizziness, particularly 
before eating. The action of the heart is often irregular, notably when 
the stomach is empty, and attacks of palpitation or dyspnoea may occur 
from apparently slight indiscretions of diet. The patient is frequently 
in a state of mental depression, or is nervous and irritable. He is 
often drowsy after eating, and wakeful at night. Although for a long 
time the general nutrition may be but little impaired, eventually emacia- 
tion, sometimes extreme, results. Extreme pallor and symptoms of a 



DISEASES OF THE STOMACH. 



833 



progressive pernicious ansemia have been observed in chronic gastritis 
with extensive atrophy of the mucous membrane. 

The tongue may be somewhat coated, though not infrequently it 
appears normal. The breath is often offensive, either from an unclean 
condition of the mouth and teeth or from the escape of gases from the 
stomach. The epigastrium is frequently swollen and tender, and splash- 
ing may be heard on palpation at a time when the normal stomach should 
be empty. The contents of the stomach removed at a suitable time after 
a test meal has been taken may be increased in quantity and contain 
undigested food from impaired motility and defective digestive power. 
There is usually a diminution of hydrochloric acid, in which case lactic, 
acetic, or butyric acid is present. It is stated, on the contrary, that in 
proliferating gastritis there may be an excess of hydrochloric acid. There 
is abundant mucus in simple catarrhal gastritis, while there is little or 
no mucus in the contents of the stomach in atrophic gastritis. In the 
latter affection in addition to diminished or absent hydrochloric acid 
there is a marked lack of the digestive ferments. The urine is scanty, 
and either is high-colored with abundant urates or is pale and contains 
phosphates ; crystals of calcic oxalate are sometimes observed. 

Prognosis. — Periods of temporary improvement during the course of 
chronic catarrhal gastritis are frequent, but recurrences of the symptoms 
are the rule. Complete recovery in primary gastritis is the less likely to 
occur the longer the condition has existed, because of the organic changes 
developing in the wall of the stomach. In gastritis secondary to grave 
disease the prognosis depends upon the conditions causing the gastric 
changes. The immediate outlook is extremely grave when the chemical 
examination of the stomach shows persistent absence of the digestive 
ferments. 

Diagnosis. — Important in diagnosis is a well-defined cause, the per- 
sistence of the symptoms, a constant lack of free hydrochloric acid, the 
presence of abundant mucus in the contents of the stomach, and evidence 
of deficient motility and absorptive power. Boas, however, has observed 
a series of cases characterized by the copious secretion of mucus and 
excessive acidity and accompanied by marked pain in the region of the 
stomach, to which he has applied the term acid gastritis. The diagnosis 
of pure chronic gastritis requires also the elimination of other affections 
of the stomach in which similar modifications of function may be present. 
Especially to be differentiated are nervous dyspepsia, dilatation, and 
cancer of the stomach. Even ulcer of the stomach, when pain is slight 
and hemorrhage lacking, may be regarded as chronic gastritis. 

Nervous dyspepsia is to be eliminated by the existence of a satisfac- 
tory local cause for the gastric symptoms, by the greater or less uniform- 
ity of relation between definite kinds of diet and the occasioned disturb- 
ance, and by the freedom from various neuroses. Dilatation of the 
stomach is to be excluded by the results of the examination with the 

53 



834 



DISEASES OF THE DIGESTIVE APPARATUS. 



tube. In cancer the cachexia is greater and usually progressive despite 
treatment, lactic acid is generally found in the contents of the stomach, 
and, as a rule, a tumor eventually is appreciable. In ulcer of the stomach, 
even if there is no characteristic hemorrhage, localized tenderness is likely 
to be marked, and the gastric pain is commonly relieved by alkalies and 
by certain foods. The differential diagnosis is further considered in the 
articles on these several diseases. 

Treatment. — The successful treatment of chronic gastric catarrh re- 
quires the most careful attention to minutise and watchfulness on the part 
of the physician to see that directions are closely carried out. A 
woollen or silk abdominal bandage to be worn day and night is in many 
cases essential. The diet must be regulated with the greatest strictness 
and care, an absolute diet-list being given to the patient. In the selec- 
tion of the diet not only must the general rules be adhered to, but the 
individual peculiarities of the patient must be carefully studied, so that 
the diet-list shall conform not only to the needs of the gastric catarrh, 
but also to those of the individual suffering from the catarrh. The per- 
sonal experiences of the patient are to be carefully weighed. In severe 
cases it may be necessary to commence the course of treatment with a 
rigid milk diet ; there are many persons who assert that milk does not 
agree with them, there are a few who really cannot digest it ; upon the 
latter it should not be forced. The milk may be warm, but never 
boiled. Ordinarily milk at the temperature of the room is to be pre- 
ferred ; ice-cold milk should never be allowed. It should be swallowed in 
small quantities, five to six ounces, every two hours during the day, and 
should have added to each portion one to two tablespoonfuls of lime 
water. It should be taken slowly, in draughts of not more than an 
ounce each, at intervals of a minute, or longer. It should not be too 
rich, and in some cases should be partially skimmed. Separator milk 
should never be used. The length of time during which a patient may 
be kept on a milk diet without injury is indefinite ; from two to four 
quarts of milk a day are necessary to support the bodily functions. 

Probably next to milk, and perhaps superior to it, in digestibility, 
is scraped beef given raw ; it is, however, so disagreeable to patients that 
immediately following the milk diet, or in mild cases without a preceding 
milk diet, the practitioner frequently must content himself with restricting 
the food to Hamburg steak (made without egg and broiled lightly over a 
very quick fire), stewed sweetbread, white meat of chicken or game, and 
pulled bread or toast. Custards made with but little sugar or sweetened 
with saccharin, and junket, may be used for desserts. Milk-toast agrees 
well with some. Game may be allowed, but tame ducks, turkey, and 
squabs or young pigeons are to be interdicted. Among vegetables, thor- 
oughly cooked spinach, macaroni stewed in milk, and rice, are the first to 
be given ; in many cases certain farinaceous foods may be taken early, 
— never oatmeal, however. Wheat preparations are usually to be pre- 



DISEASES OF THE STOMACH. 



835 



ferred, though some of the fine Indian-corn preparations are useful. The 
hull of the grain must be largely removed, and the farinaceous food must 
be thoroughly cooked. A principle of absolute importance is that not 
more than three or four different foods should be taken at one meal. 
As the case progresses, or the patient becomes utterly wearied, the diet 
may be extended by the addition of fresh young vegetables. Too long 
continuance of any diet may lead to loss of appetite with weakness and 
anseniia. 

All vegetables that are eaten green, such as peas, should be very 
young and soft ; ripe peas and beans are among the most indigestible 
of farinaceous foods. Potatoes are among the last articles to be allowed ; 
they should always be roasted and mealy. Sugar is distinctly worse 
than potatoes. Artificial foods, peptones, etc., much used as they are, 
are, in our belief, not to be looked upon with favor, as it is impossible 
for any one to know what a pharmaceutical food really contains. The 
food must be thoroughly masticated. 

The question of drink is an important one. In the first place, alcohol 
is an irritant to the stomach, and in chronic inflammation of this organ 
can only do harm, so that total abstinence must be enforced. In the 
second place, an excess of fluid with food dilutes the gastric juice, whilst 
any cold drink or food put into a diseased stomach during a meal inter- 
feres with its functions. Ice-water must be absolutely forbidden, and it 
is essential in many cases that the liquid taken during a meal be restricted 
to one teacup of weak hot tea or simple hot water. Coffee and chocolate 
are distinctly deleterious, though sometimes the demand for coffee from a 
patient is so urgent that it may be allowed once a day, preferably taken 
without cream. 

Gastric lavage has been much used in the treatment of chronic gastri- 
tis 5 when there is any interference with the escape of food through the 
pylorus, or when there is dilatation of the stomach, it may be essential ; 
but in the great majority of cases of catarrh lavage is unnecessary and 
even harmful. Its use is apt to develop into a very deleterious habit : thus, 
we have known a sufferer to take habitually forty or fifty lavages a day. 

In most cases of chronic gastric catarrh there is constipation, and even 
when it is not pronounced, cure is facilitated by keeping the bowels in a 
soluble condition. It is probably by its action on the liver and the por- 
tal circulation that the Carlsbad water and salts have acquired their 
great reputation. It is doubtful whether these European waters and 
the salts prepared from them are in any way superior to the Bedford 
water of Pennsylvania or the stronger springs of the Saratoga district 
in New York. In our practice the Carlsbad salts used at home have 
not seemed superior to saline mixtures. (See formula 19.) In some 
cases it has been advisable to alternate this formula with that of the 
aloes and senna mixture. (See formula 20.) Formulas 2 and 3 may 
also be used on occasion. The laxative should be administered daily, 



836 



DISEASES OF THE DIGESTIVE APPARATUS. 



so as to maintain a steady impression, and in snch doses as to produce 
semi-solid stools.* 

As regards the direct medicament of the stomach, the first principle is 
to avoid doing harm. All irritating substances are injurious ; quinine, 
gentian, quassia, and other so-called " simple bitters," strychnine,, aro- 
matics, spices, should all be rigorously avoided. In any dose and in all 
doses they are incapable of good (except in alcoholic cases), and may do 
great harm ; in some highly angenlic cases minute quantities of iron, 
such as occur in some mineral waters, are not disadvantageous. 

The one remedy that is useful is silver nitrate. Its action is purely 
local, and direct contact with the mucous membrane is essential. It should 
never be administered in solution, as when it is so given decomposition 
begins from the moment it touches the lips. Further, the mucous mem- 
brane should be prepared for its action ; a tumbler of hot water con- 
taining ten grains of sodium bicarbonate should be taken half an hour 
before each meal, followed in ten minutes by a pill of one-quarter grain 
of the nitrate with half a grain of extract of hyoscyamus. In severe 
cases the nitrate should be exhibited for from one to two months, the 
best results often being obtained by breaking the treatment up into 
periods of two or three weeks. During these interruptions bismuth 
subnitrate may be used, but resorcin, one to two grains, in solution, is 
usually more effective ; and even zinc oxide (dose one grain) often acts 
better. The inferiority of these drugs, however, to the nitrate is very 
great. During the prolonged exhibition of the nitrate the inside of the 
lips and the gums should be watched for the appearance of the first 
evidence of approaching argyria ; any discoloration should be the signal 
for the immediate withdrawal of the drug. The danger of argyria is, 
however, we think, greatly exaggerated ; in our own practice we have 
never seen but one case in which the slightest show of color appeared 
upon the lips. 

When in any case of gastric catarrh there is pronounced tendency to 
fermentation of food which is not controlled by regulation of the diet, a 
capsule of naphtol (2.5 grains) and carbolic acid (1 grain) is often very 
serviceable. 

Chronic gastric catarrh of alcoholic origin differs from that of a 
different etiology in that the mucous membrane by long habit has become 
accustomed to irritants and often bears bitters well, seemingly being for 
the time benefited. Even in these cases, however, the sooner such drugs 
are got rid of the sooner will complete restoration be brought about. 

ULCER OF THE STOMACH. 

This disease is variously designated according as the anatomical, the 
clinical, or the etiological characteristics are made conspicuous. It is 



* The student should also compare this article with that on hepatic congestion. 



DISEASES OF THE STOMACH. 



837 



called round from its frequent shape, chronic from its usual prolonged 
existence, perforating since it shows a tendency to destroy the wall of the 
stomach, and corrosive or peptic from the supposed importance in its pro- 
duction of the digestive qualities of the contents of the stomach. Similar 
ulcers are seen also in the duodenum, and more rarely at the lower end 
of the oesophagus. 

Etiology. — It is generally recognized that the factors of chief impor- 
tance in etiology are a localized diminution in the blood-supply to the 
wall and superacidity of the gastric juice, and severe burns are some- 
times followed by duodenal ulcer. Local causes of a diminished circu- 
lation are to be found in injuries to the surface, arterial obstruction from 
sclerosis, thrombosis, or embolism, and spasmodic contraction of the mus- 
cular coat of the arteries ; and Easmussen considers that pressure upon 
the stomach from a tight band around the waist may be of etiological 
importance. The local enfeeblement of the circulation becomes intensi- 
fied in general deterioration of the blood, as in anaemia, chlorosis, and 
tuberculosis. Ulcer of the stomach is twice as common in women as in 
men, and, according to Welch, is oftenest found in the former between 
the ages of twenty and thirty years, and in men between thirty and forty. 
It is of relatively frequent occurrence, being present in five per cent, 
of a large number of autopsies. Female domestics, particularly cooks, 
are usually considered to be especially liable, but gastric ulcer is found in 
all classes in life. Ulcer of the duodenum, on the other hand, is more 
common in men. 

Morbid Anatomy. — The shape of the ulcer is round or oblong, and 
is often compared to that of a funnel, from the fact that one part is often 
shelving, even in terraces, towards the sharply defined deepest point. The 
terraced appearance is due to the more extensive destruction of the mucous 
than of the muscular coat, and of the muscular than of the subperitoneal 
coat. Eventually a like destruction of all the coats takes place, and the 
ulcer appears as if a hole had been punched in the wall of the stomach. 
The size of the ulcer varies from one a half-inch in diameter to another 
covering a surface of the size of the palm of the hand. One or several 
ulcers are to be found, and the largest result either from the confluence 
of two or more or are due to the progressive enlargement of a single 
ulcer. The edge is sharply defined, and often shows at one point the 
stump of an artery perhaps obliterated either by a thrombus or by endar- 
teritis. The gastric ulcer is generally found in the pyloric half of the 
stomach near the smaller curvature, and on the posterior wall. Its 
proximity to the smaller curvature and its peculiar shape are com- 
monly attributed to the arborescent distribution of the branches of an 
obstructed coronary artery. 

The tendency of the ulcer is towards healing or perforation. The 
healed ulcer is manifested by a scar often radiating, which, if at the 
pylorus or in the duodenum, is likely to cause a stenosis, resulting in 



838 



DISEASES OF THE DIGESTIVE APPARATUS. 



dilatation of the stomach. The healing of an ulcer of the middle third 
of the stomach extensive enough to involve a considerable portion of its 
circumference is one of the causes of an hour-glass shape of the stomach. 
The scar of a previous ulcer and the clean-cut destruction of an active 
ulcer are to be found not infrequently in the same stomach. The ulcer 
about to perforate is often prevented from causing the escape of the con- 
tents of the stomach by the formation of fibrous adhesions between the 
peritoneal coat of the stomach and the peritoneal covering of neighbor- 
ing structures, as the liver, spleen, pancreas, and diaphragm, which make 
the base of the ulcer after perforation has taken place. The digestive 
action of the gastric juice takes place in them, and extensive destruction 
sometimes ensues. If destruction of the adhesions or of the peritoneum 
at the base of the ulcer ensues, the escape of the contents of the stomach 
causes a general or circumscribed acute peritonitis. Perforation of the 
diaphragm has occurred, leading to the passage of the contents of the 
stomach into the pleural and pericardial cavities, and in rare instances 
the wall of the heart has been perforated. Fistula have been formed 
between the stomach and the duodenum or the colon, and the abscess fol- 
lowing perforation of the stomach has been evacuated into the intestinal 
tract or through the abdominal wall. Profuse and often fatal hemorrhage 
results from the perforation of arteries or veins which lie in the edge or at 
the bottom of the ulcer, as the pancreatic or the coronary artery, branches 
of the splenic artery, the hepatic artery, and the splenic or portal veins. 

Symptoms. — There may be no symptoms indicative or suggestive of 
the presence of a gastric ulcer. As a rule, excessive acidity or secretion 
precedes and accompanies disturbances which are more directly attrib- 
utable to the ulcer : hence for a longer or shorter period complaint is 
made of epigastric distress, relieved by food, especially by albuminous 
substances, of pyrosis, particularly during the height of digestion, of 
vomiting of an acrid fluid when the stomach contains no food, and of 
excessive appetite and frequent headache. 

The most significant symptoms are localized pain, tenderness, and 
hemorrhage. The pain is burning or gnawing in character, and usually 
becomes more severe within an hour after food has been taken. It is 
sometimes intense, especially when indigestible articles of food are taken, 
and may be greatly relieved by bland liquids, as milk, freely diluted with 
an alkaline water ; when so severe as to cause vomiting, relief is often 
immediately experienced when the stomach is emptied. The pain is dif- 
fused over the epigastrium, and at times radiates in all directions, extend- 
ing even to the shoulders. It is apt to persist throughout the process 
of digestion, and is not infrequently increased on motion and in certain 
positions. Pressure sometimes aggravates, at other times lessens, the 
pain. 

In addition to the diffused and radiating pain, circumscribed tender- 
ness is frequent, usually midway between the ensiform cartilage and the 



DISEASES OF THE STOMACH. 



839 



navel, and at times is perceptible only on deep pressure. A tender spot 
is sometimes to be felt on the left of the spine in the immediate vicinity 
of the lower dorsal vertebrae, especially when pain from the nicer extends 
into the back. According to Boas, this dorsal tenderness is present in 
one-third of the cases. 

Easily recognized hemorrhage occurs as a symptom of ulcer in at least 
one-third of the cases, but slight bleeding not manifested by characteristic 
symptoms or signs is probably of far more frequent occurrence. The blood 
is either vomited, hcematemesis, or appears in the stools, melcena, and not 
infrequently the black discoloration of the stools continues for a num- 
ber of days after blood has been vomited. Hsematemesis may be the first 
symptom exciting the suspicion of an ulcer, and may be so severe as to 
prove an immediate cause of death. Usually, however, it occurs after 
the attacks of pain have existed for some time. The vomiting of blood 
may come on at any time and without obvious cause ; on the other hand, 
it may follow an error in diet or muscular strain. It is often immediately 
preceded by a sensation of faintness, and the patient may be in a state of 
collapse before blood is vomited, and may die even without the blood 
making its appearance externally. When blood is vomited it is usually 
abundant, dark red, liquid or clotted, either clear or mixed with food, 
dependent upon the length of time it remains in the stomach and upon 
the period of digestion. The attack of hseniatemesis usually ceases when 
the stomach is emptied of its contents, although a number of recurrences 
at intervals of hours or days is not infrequent, after which months or 
years may elapse before this symptom returns. 

For a long time the nutrition may be sufficient, but emaciation in 
protracted cases is often extreme. The disturbance of nutrition is due 
in part to the avoidance of food in consequence of the distress it pro- 
duces, and in part to the complications occurring in the course of ulcer, 
especially to dilatation of the stomach from cicatricial stenosis. Anaemia 
is conspicuous while hemorrhage from the ulcer is taking place. The 
tongue is usually clean, and palpation of the abdomen, in addition to 
making known localized tenderness, in chronic cases sometimes discloses 
a circumscribed induration due to a thickening of the wall of the stomach 
from chronic perigastritis. The chemical examination of the contents of 
the stomach ordinarily shows superacidity, from two to three per cent, 
of free hydrochloric acid usually being found. Subacidity, however, 
may be present when there has been excessive loss of blood or a compli- 
cating chronic gastritis, with or without dilatation of the stomach. The 
chemical condition of the contents of the stomach is to be determined 
only by examination of the vomit, since the use of the tube may prove 
a source of danger by causing hemorrhage or perforation. 

The healing of the ulcer is followed by relief to the characteristic 
symptoms, although these may be replaced by those of dilatation of the 
stomach when stricture of the pylorus is caused by the scar. The symp- 



840 



DISEASES OF THE DIGESTIVE APPARATUS. 



toms last to disappear are those of superacidity, but after longer or 
shorter intervals of freedom from disturbance recurrences are likely to 
take place. The persistence of the symptoms of ulcer usually results 
from its extension, especially to parts in the vicinity of the stomach after 
the wall has been perforated. The perforation of the stomach may be 
suddenly announced by intense abdominal pain, followed by a tense, 
swollen, tympanitic, and tender abdomen, with absence of hepatic dul- 
ness, and by a febrile temperature, rapid respiration, and vomiting. 
The symptoms indicative of peritonitis from perforation are more likely 
to occur when the ulcer is seated in the anterior wall. When the pos- 
terior wall is perforated the symptoms of acute perforation are usually 
absent, owing to the previous formation of more or less dense fibrous 
adhesions, and fever also is lacking unless a subphrenic abscess, an omen- 
tal bursitis, or an abscess of the liver, spleen, or pancreas result from 
the perforation. 

Diagnosis. — The diagnosis of ulcer of the stomach may be very diffi- 
cult, especially when there is no hemorrhage. The pain from ulcer of 
the stomach is the result of the action of the irritating contents of the 
stomach upon the gastric nerves in general, as well as upon those exposed 
by the ulcer. Pain referred to the stomach, however, is of very frequent 
occurrence independent of ulcer, and especially to be eliminated is the 
gastralgia occurring as a neurosis. This is found in persons of a neu- 
rotic temperament not infrequently suffering from other neuralgias, and 
occurs in paroxysms with intervals of freedom from symptoms of diges- 
tive disturbance, is neither induced nor relieved by any especial variety 
of food, and is often diminished hj pressure and the use of electricity. 
Gastric crises of pain in locomotor ataxia may suggest those of ulcer, 
but this disease is to be excluded by the presence of normal pupillary 
and patellar reflexes. An attack of biliary colic has suggested pain from 
ulcer of the stomach, but the character of the pain is griping, vomiting 
affords no relief, the liver and the gall-bladder are enlarged and tender, 
and jaundice is likely to follow. No absolute importance is to be at- 
tached to the seat and time of occurrence of the pain as determining the 
position of the ulcer, although the occurrence of pain several hours after 
eating and of nielsena is suggestive of the situation of the ulcer in the 
duodenum. Superficial tenderness is indicative of ulcer rather of the 
anterior than of the posterior wall, and deep-seated pain and tenderness, 
especially when the latter is to be found in the back, are suggestive of 
ulcer of the posterior wall. If continual relief to the pain is experienced 
in any one position, it not infrequently results that the affected part of the 
stomach lies uppermost in the position giving relief to pain. 

The hsematemesis may be the result of various causes besides ulcer, as 
cancer, fibrous hepatitis, the rupture of an aneurism, poisons, foreign 
bodies, and infectious diseases. The history of the case and the associated 
symptoms are usually sufficient to eliminate many of these causes. In 



DISEASES OF THE STOMACH. 



841 



cancer of the stomach the hemorrhage is likely to be more frequent but is 
less abundant than in ulcer, and generally is of a coffee-grounds character. 
The pain is not so intense, is rather continuous than paroxysmal, and is 
not so directly affected by the nature of the food. The tumor of cancer 
is larger and more irregular than the palpable induration from chronic 
ulcer. The symptoms are suggestive of subacidity, and the contents of 
the stomach, as a rule, show deficient hydrochloric acid. The hseniatem- 
esis from fibrous hepatitis is to be excluded by the physical examination 
of the liver and spleen, which shows atrophy of the one and enlargement 
of the other. The hemorrhage in this disease is likely to be both intes- 
tinal and gastric, the blood in the stools often being fresh, and not black 
or tarry, as in ulcer of the stomach or of the duodenum. Hemorrhage 
from a ruptured aneurism is usually immediately fatal, and is generally 
preceded by symptoms indicative of the presence of an aneurism. 

Prognosis. — The prognosis of ulcer of the stomach as to life is 
ordinarily favorable, but the patient may suffer from continuous or re- 
current symptoms for many years. Although the disease is more fre- 
quent between the ages of twenty and forty, the mortality is greater from 
forty to sixty. Death occurs in about fifteen per cent, of the cases. It 
is due to peritonitis from perforation in about one-half of these, and to 
hemorrhage in about one-third. Persistence of pain irrespective of the 
quality of food, and extreme tenderness, are serious symptoms, since they 
suggest an advancing ulcer and impending perforation. Peritonitis from 
perforation, however, though usually fatal, is not invariably so, especially 
when a circumscribed abscess is the result. Profuse hemorrhage is in- 
dicative of the perforation of a large blood-vessel, and, therefore, is evi- 
dence of a deep ulcer, the healing of which takes place with difficulty, 
and the tendency of which is towards perforation. 

Treatment. — In the treatment of gastric ulcer it is often wise to put 
the patient to jbed for a length of time, in order to favor quiet of the 
stomach and to save the general strength. 

The first indication is to check gastric movements ; the second, to 
render as far as possible the gastric contents unirritating to the stomach ; 
the third, to make local applications which shall favor the healing of the 
ulcer. 

Unfortunately, there is no known drug which has the power of 
checking peristaltic movements of the stomach, unless it is opium ; in- 
deed, it is far from certain that doses of this narcotic not sufficiently large 
sensibly to derange the general health have such power. The ingestion 
of food such as occurs at an ordinary meal undoubtedly calls into func- 
tional activity the glands and the muscular walls of the stomach ; hence 
total abstinence from stomach-food for some days is often prescribed in 
gastric ulcer, the patient being sustained by the use of nutritive enemata. 
It is not clear, however, that small quantities of bland food, such as 
milk, excite the viscus, and according to our experience total abstinence 



842 



DISEASES OF THE DIGESTIVE APPARATUS. 



from stomach-food is of doubtful utility, and should be enforced only in 
severe cases after the failure of other measures. It usually suffices to 
reduce the stomach-food to an ounce of milk with one tablespoonful of 
lime water taken every one or two hours. Even this restriction of diet 
cannot be with safety maintained for an indefinite time, so that after a 
few days the milk should be increased, or bouillon with egg (the egg to 
be rapidly stirred into the bouillon whilst it is boiling hot, immediately 
on its removal from the fire), and various purees, — as of chicken or of 
sweetbread,— junket, and custards, may be allowed. Next, scraped raw 
beef may be taken, then stewed sweetbread, then Hamburg steaks. Any 
food should be given in small quantity at short intervals. 

The drugs which are used in gastric ulcer are bismuth subnitrate, 
silver nitrate, resorcin, zinc oxide, and oil of turpentine. Of these drugs 
we have never seen any distinct effects from bismuth. The oil of turpen- 
tine in the ordinary case will do great hurt ; it is to be used only, and 
then very cautiously, in very old cases in which there is such a history 
as to warrant the belief that the ulceration has existed continuously for a 
great length of time. Silver nitrate is by far the most generally useful ; 
it should be given as in chronic gastritis. Eesorcin in doses of one to two 
grains is sometimes of service. Zinc oxide may be tried, but is usually 
inefficient. 

In all cases of gastric ulcer constipation should be carefully guarded 
against ; mercurials are occasionally of advantage ; salines should be 
exhibited as in chronic gastritis. 

Excessive vomiting often yields to very careful and restricted feed- 
ing, but if it continue is to be met by the use of cracked ice, by fomenta- 
tions or a small blister upon the epigastrium, and by the exhibition of 
cocaine, or bismuth, or cerium oxalate. In obstinate cases lavage is fre- 
quently of great service ; rarely opium suppositories are necessary. 

Gastralgia may be so severe as to require active treatment. Sodium 
bicarbonate, in doses of ten grains or more well diluted, will sometimes 
bring relief. Hot applications and sinapisms applied to the epigastrium 
are often useful. The combination of prussic acid and cocaine (formula 
26) is sometimes serviceable, but in severe paroxysms opium must be 
used. Antifebrin and antipyrin are very rarely effective in a gastralgia 
dependent upon ulceration. The use of irritating substances, such as 
chloroform and Hoffmann's anodyne, always endangers aggravation of the 
original disease. 

Hemorrhage. — In cases of serious gastric hemorrhage all food should 
be temporarily withheld from the stomach, the patient being sustained 
by nutritive enemata ; or milk and lime water should be given at short 
intervals in very small doses. Opium should be administered in such 
dose as to produce distinct quiet and obtunding of the nervous system ; 
very commonly suppositories of extract of opium, one grain, and extract 
of belladonna, one-sixth of a grain, afford the best method of exhibition. 



DISEASES OF THE STOMACH. 



843 



Of all the haaniostatic drugs, MonseFs solution is the most powerful; it 
should be exhibited in doses of one to two drops from every ten minutes 
to every hour, pro re nata, great care being exercised to avoid vomiting. 
Extract of ergot may be given hypodermically, as in haemoptysis ; ice 
should be freely applied over the stomach. If a hemorrhage from the 
stomach depends upon congestion of the portal circulation, a mercurial 
or saline purge may be of great benefit ; if, however, the cause of the 
bleeding is ulceration, purgatives are to be avoided unless there has been 
pronounced and persistent constipation. 

When the bleeding is from an ulceration there is a strong incen- 
tive to attempt its surgical arrest ; the difficulties, however, of locating 
a bleeding spot, the uncertainty at any moment whether there will be 
further bleeding, and the danger of death from shock in an exsanguined 
person render the operation a very dubious procedure. Moreover, at 
present there is no sufficient evidence from recorded cases to guide the 
surgeon. 

Perforation. — When perforation of the stomach occurs slowly, with 
the formation of abundant adhesions and a resultant secondary abscess, 
no other treatment may be needed than the evacuation and surgical treat- 
ment of this abscess. When the perforation is abrupt and accompanied 
with serious symptoms, radical surgical interference should be imme- 
diate ; each hour of delay sensibly increases the risk to life. According 
to the statistics of Eichardson, in forty-four such operations the mor- 
tality was 77.27 per cent., although the last twenty-one cases gave a 
mortality of only 57.01 per cent., the difference probably being due to 
improvement in surgical technique. 

Surgical removal of an ulcer has been performed in a few cases, usually 
with fatal results. It seems to us not justifiable unless called for by 
excessive hemorrhage, by perforation, or by narrowing of the pyloric end 
of the stomach through progressive cicatricial contraction. 

CANCER OF THE STOMACH. 

Cancer of the stomach occurs in from thirty-five to forty per cent, of 
cases of cancer. According to Wyss, in middle Europe two per cent, of 
deaths are due to gastric cancer. The frequency of this disease somewhat 
varies, however, in different countries, and in New England the mortality 
from cancer of the stomach is about one-half of one per cent. 

Etiology. — Cancer of the stomach occurs with nearly equal frequency 
in the two sexes. About three-fourths of all cases occur between the 
ages of forty and seventy years, and two-thirds between forty and sixty 
years. Heredity seems of importance in etiology in a certain number 
of cases. The significance of local irritation is suggested by the great 
frequency of cancer at the narrowest portion of the stomach, mainly at 
the pylorus, and by the previous occurrence of ulcer in about six per 
cent, of the cases. 



844 



DISEASES OF THE DIGESTIVE APPARATUS. 



MoFvBiD Anatomy.— Cancer of the stomach is either primary or sec- 
ondary, the former representing a growth arising in the deeper layer of 
the mncons membrane, the latter often extending inward from the peri- 
toneal coat of the stomach. Primary cancer alone is of especial clinical 
importance. The varieties usually recognized are the medullary, fibrous, 
hyaline (gelatinous or colloid), and cylindrical- cell cancer. The growth 
occurs as single or multiple nodules, or as a diffused infiltration of the 
wall, which sometimes involves the entire stomach. The disease is seated 
at the pylorus in more than one-half of the cases, next in frequency at 
the smaller curvature, more rarely at the larger curvature, in the ante- 
rior or posterior wall, or in the vicinity of the oesophageal opening. 
Modular cancer, as it increases in size, projects above the mucous mem- 
brane of the stomach, spreads laterally and in depth, its surface being 
smooth, lobulated, or j>apillate, and its edge often everted. The medul- 
lary variety of cancer is soft and often exceedingly vascular, while the 
fibrous and hyaline varieties are dense and contain few and compara- 
tively small blood-vessels. As the nodules increase in size, hemorrhage 
or necrosis is likely to take place in them, and the portions of the tumor 
thus altered are readily corroded by the gastric juice, and the cancerous 
ulcer results, which tends to extend in depth until perforation of the 
stomach ensues. In about three per cent, of the cases perforation takes 
place into the general peritoneal cavity, and a fatal peritonitis follows. 
Usually, however, adhesions are formed between the stomach and the 
liv^er, spleen, pancreas, or diaphragm before actual perforation takes 
place, and these form the base of the cancerous ulcer when the wall of 
the stomach is destroyed. The cancerous growth extending into these 
structures in turn becomes softened and corroded by the gastric juice, 
and large cavities are formed outside of the stomach, but freely com- 
municating with it. Food enters these cavities, and, becoming decom- 
posed, causes an acute inflammation, which may result in abscesses and 
thrombophlebitis. The adhesive inflammation preceding perforation may 
take place also between the stomach and the abdominal wall, the colon, or 
the small intestine, and a cutaneous or gastro-intestinal fistula follow the 
perforation. A tumor at the pylorus often causes obstruction at this 
orifice, with secondary dilatation of the stomach, although occasionally a 
sufficient compensatory hypertrophy of the wall results. The mucous 
membrane of the stomach affected by cancer presents the characteristics 
of a chronic gastritis. 

Infiltrating cancer of the stomach is usually either fibrous or gelati- 
nous, and all the coats of the stomach are invaded, although the mucous 
and muscular coats are more especially altered. A limited portion of the 
stomach or the entire organ may be infiltrated, and the stomach is accord- 
ingly either enlarged or diminished in size. The diminution in size is 
most marked in case of the infiltration of the wall by fibrous cancer, 
and the gross appearances may resemble so closely those of the cirrhotic 



DISEASES OF THE STOMACH. 



845 



stomach of chronic gastritis that microscopical examination will be neces- 
sary to enable the differential diagnosis to be made. In fibrous cancer 
or scirrhus the anatomical diagnosis is not infrequently suggested by the 
recognition of evidence of cancer elsewhere. 

The extension of the cancer from the stomach to other organs is fre- 
quent. The lymph-glands near the smaller curvature of the stomach are 
offcenest diseased, and from these the cancer may extend to remote lymph- 
glands, especially to the supraclavicular and to the inguinal lymphatic 
glands. Extension to the liver takes place in about one-third of the 
cases, either directly after adhesions are formed or by means of the portal 
circulation. The peritoneum often becomes cancerous by the extension 
of the disease from the stomach not only in the immediate vicinity of 
this organ, but also at remoter parts, frequently at the bottom of the 
pelvis in Douglas's fossa. Cancer may extend from the stomach through 
the peritoneum to the diaphragm, through the diaphragm to the pleura, 
and thence to the lungs, or it may invade the lungs, brain, and other 
parts of the body by means of the circulation. 

Symptoms. — Pain, vomiting, and cachexia, and tumor in the region 
of the stomach, are the conditions suggesting cancer of this organ. The 
development of the cancer is not infrequently preceded for a long time 
by symptoms of chronic gastritis, although occasionally there is no inter- 
ference whatsoever with digestion until the onset of the symptoms attrib- 
utable to the presence of cancer ; and in elderly persons especially the 
symptoms may be exceedingly obscure. Pain is one of the earliest symp- 
toms, is present in three-fourths of the cases, and is generally limited to 
the epigastrium, although sometimes extending into the sides, the back, 
and more rarely to the shoulders. It is usually constant, although often 
somewhat aggravated after eating. The pain is described as dragging, 
burning, gnawing, or cutting, and exceptionally is as intense as in ulcer 
of the stomach. 

Vomiting is the most constant symptom, and occurs either early or 
late in the course of the disease in four- fifths of the cases. It is more 
likely to be absent when the cancerous growth is at some distance from 
the orifices of the stomach. Its occurrence is almost invariable in cancer 
of the pylorus, and the quantity vomited may then be large in conse- 
quence of secondary dilatation of the stomach. The frequency of the 
vomiting gradually increases with the progress of the disease, and event- 
ually is likely to become extreme. The immediate act of vomiting has 
no definite relation to the taking of food ; indeed, it may occur when the 
stomach is empty ; nor does the time at which vomiting takes j)lace bear 
any definite relation to the seat of the tumor. It is asserted, however, 
that vomiting soon after eating is frequent in cancer seated at the cardiac 
end of the stomach, while vomiting occurring an hour or later after eating 
is more likely to be connected with pyloric cancer. The vomit is sour, 
and consists of food, often incompletely digested, and of mucus, and may 



846 



DISEASES OF THE DIGESTIVE APPARATUS. 



contain fragments of the cancer. Blood is present from time to time in 
nearly one-half of the cases, but is rarely so profuse as in gastric ulcer, 
and frequently resembles coffee-grounds in consequence of its gradual 
oozing, prolonged retention, and partial digestion. 

Cachexia, the bad state or habit of the patient, begins early, progresses 
continuously, and is chiefly dependent upon the interference with gastric 
digestion and upon the hemorrhage : it is also influenced by the extension 
of the disease to other parts, especially to the biliary tract. The patient 
is usually thin, pale, at times somewhat jaundiced, the expression of the 
face is often one of suffering, and oedema of the skin, especially of the 
legs and feet, is frequent. 

Tumor is to be recognized early or late in the course of the disease in 
about four-fifths of the cases, and the infiltrating cancer causes rather a 
diffuse resistance than a circumscribed induration. Tumors of the lesser 
curvature become apparent only when the stomach is dislocated down- 
ward, and then are made conspicuous often from the associated extension 
of the disease to the neighboring lymphatic glands. "When the tumor is 
small it is frequently concealed beneath the left lobe of the liver, but 
is even then sometimes brought within reach by prolonged inspiration. 
As it increases in size, especially when free from adhesions, it is freely 
movable, and is generally to be felt and often to be seen in the epigas- 
trium or in the hypochondriac regions, and exceptionally may descend 
so far as to lie in the vicinity of the symphysis pubis. The tumor is 
usually sharply defined, rounded, or irregularly nodulated, hard, and 
often tender. The tumor, though commonly movable, when non -adherent 
changes its position but little during respiration ; indeed, its ascent on 
inspiration is easily prevented by pressure of the hand ; but when the 
entire stomach is infiltrated with cancer the respiratory movements of 
the diaphragm are readily transmitted. When adherent to the liver its 
motility is limited by that of this organ, and when united to the pan- 
creas or to the posterior abdominal wall it is rendered immovable. It 
frequently transmits the pulsations of the aorta when the patient is 
supine, but in the knee-elbow position the pulsations are not transmitted 
unless the tumor is adherent in the vicinity of the aorta. The movable 
tumor is sometimes more readily felt when the patient is on his hands and 
knees. When the stomach is inflated a tumor of the anterior wall is 
often made more conspicuous, while that seated in the posterior wall is no 
longer to be felt. The position of the tumor at the greater curvature of 
the stomach may be made evident by distention of the colon with air or 
water. 

During the progress of cancer of the stomach the appetite is usually 
feeble, there is frequent nausea, and the disturbances of digestion found in 
chronic gastritis or in dilatation of the stomach are often present. There 
may be, however, a good appetite and but little disturbance of digestion. 
The bowels are usually constipated, and the dejections are often black 



DISEASES OF THE STOMACH. 



847 



from the presence of blood even when hsematemesis is absent. The urine 
is often diminished in quantity, is usually alkaline or neutral, and fre- 
quently contains an excess of indican. A considerable leukocytosis is 
frequent. 

Cancer of the stomach lasts from one to three years, the shorter period 
being the limit of life generally following the discovery of the tumor. 
Death is apt to result from progressive loss of flesh and strength essen- 
tially from starvation, unless extension to the serous membranes, pulmo- 
nary embolism, or an acute inflammatory complication, as peritonitis 
from perforation, supervenes. Towards the end of life frequent chills 
followed by fever and suggestive of malarial infection at times occur, and 
are due probably to foci of suppuration either in the vicinity of a per- 
forating cancer of the stomach or in the liver or lungs. Profound disturb- 
ance of the nervous system occasionally occurs towards the end of life, 
the symptoms resembling those occurring in diabetic coma. The patient 
at first is restless and wakeful, the respiration becomes deep, and the 
pulse is rapid and weak. Drowsiness supervenes, and terminates in coma, 
in which death takes place. In such cases acetone and diacetic acid have 
been found in the urine. 

Diagnosis. — The positive diagnosis of cancer of the stomach before a 
tumor is discovered or particles of cancer are to be found in the vomit is 
impossible. This disease is to be suspected if the symptoms of chronic 
gastritis persist without obvious cause and are associated with cachexia 
out of proportion to the severity of the digestive disturbance, especially 
in elderly persons. When pain and hsematemesis also are present and 
tumor is not apparent, the differential diagnosis practically lies between 
chronic gastritis, ulcer, and cancer. Chronic gastritis is to be eliminated 
by a lack of cause, a cachexia greater than the digestive disturbances 
suffice to account for, considerable pain and tenderness, absence of hgem- 
atemesis, and the usual inability to arrest the progress of the disease. 
Ulcer of the stomach is to be eliminated by the age of the patient, the 
absence of intense pain occasioned by certain foods and relieved by others 
and by alkalies, the lack of profuse hemorrhage, absent superacidity of 
the contents of the stomach, existing cachexia, and failure of relief from 
treatment. The diagnosis of cancer of the stomach is based upon the age 
of the patient, the persistence of the pain, the rapid progress of the 
cachexia, often after years of digestive disturbance, coffee-grounds vomit, 
or nielsena, and usual failure to improve under treatment. 

The discovery of a tumor in the region of the stomach is the diag- 
nostic sign of greatest importance, and, whether present or absent, search 
should be made also for possible secondary tumors elsewhere, especially of 
the supraclavicular and inguinal glands and of the peritoneum in Doug- 
las's fossa. Other neoplasms than cancer may grow from the wall of the 
stomach, but, with the exception of sarcoma, usually give rise to little or 
no disturbance of digestion. The distinction between sarcoma and cancer 



848 



DISEASES OF THE DIGESTIVE APPARATUS. 



is rather histological than clinical. Foreign bodies in the stomach are 
generally to be excluded by the history of the case and by the absence of 
the extreme cachexia of cancer. The resistance due to acute perigas- 
tritis or acute pancreatitis is sudden in its origin and rapid in its 
progress. Cancer of the liver or gall-bladder changes position with 
respiration, and is not associated with the gastric pain, persistent vomit- 
ing, and hsematemesis of cancer of the stomach. Impacted faeces in the 
colon are to be excluded by means of treatment. A movable kidney is 
to be replaced in the position of the kidney, and a tumor of the abdomi- 
nal wall is unaccompanied by the gastric symptoms of cancer. 

The importance of the results of the chemical examination of the con- 
tents of the stomach removed after a test meal is still a matter of opinion. 
Persistent subacidity or inacidity, from the lack of hydrochloric acid, 
usually exists, although in the rare cases in which cancer follows ulcer 
an excess of this acid has been found. The persistent presence of lactic 
acid, which is due to stagnation of the gastric contents, occurs oftenest in 
cancer of the stomach, and therefore is important in the way of sugges- 
tion. According to Boas, it is always absent in atony, in chronic gastritis, 
and in dilatation of the stomach from pyloric stenosis. Its asserted value 
as a test of the early stage of cancer is denied by Bosenheim, who regards 
it as evidence rather of a late than of an early stage of the disease. Since 
the presence of lactic acid in the contents of the stomach may result 
from other pathological conditions, and cancer may be present without 
lactic acid, it is evident that its presence in the contents of the stomach 
is of relative, not of absolute, value in the diagnosis of cancer. 

Prognosis. — Cancer of the stomach is fatal, and death occurs the 
sooner the greater the cachexia and the more persistent the hemor- 
rhage, unless early extirpation by surgical treatment proves efficacious 
in preventing recurrence of the disease. The statistics recently given 
by Wolfler show an average mortality from resection of the pylorus of 
thirty- one and two-tenths per cent, in one hundred and seventy- three 
cases operated upon between 1888 and 1896, and of sixteen to twenty- 
five per cent, in the practice of a few surgeons. The mortality from the 
operation is twice as great when adhesions are present. Two patients 
have lived eight years after resection of the cancerous pylorus, four have 
lived more than five years, three have lived more than four years, and 
fourteen have lived from two to four years after the operation. The 
average duration of life after resection is one and a half years. Gastro- 
enterostomy, the mortality from which since 1888 in one hundred and 
ninety-five cases is thirty per cent., is usually inefficacious in prolonging 
life, though when successful it affords relief to symptoms and has been 
followed by more than two years of life. 

Treatment. — The medical treatment of cancer of the stomach is 
purely palliative. By very careful feeding, by the use of lavage (see 
Dilatation of the Stomach), by the occasional administration of creosote, 



DISEASES OF THE STOMACH. 



849 



guaiacol, silver nitrate, or bismuth subnitrate, and by the cautious use 
of morphine when necessary to relieve pain, the patient should be kept 
as comfortable as possible. In a number of cases surgical exsection has 
been performed. When the tumor can be felt through the abdominal 
wall the probabilities are always that the disease involves so much 
tissue that surgical interference offers but little hope of permanent cure. 

GASTRIC NEUROSES. 

Definition. — Modifications of gastric function independent of ana- 
tomical lesion, and attributable to disturbances of the nervous system. 

Etiology. — Essential in the production of gastric neuroses is undue 
excitability of the nervous system : hence they are more common in 
the young than in the old, in women than in men, in neurasthenia, 
hysteria, hypochondriasis, chlorosis, splanchnoptosis, and pregnancy, 
and in sufferers from Graves's disease. The disturbances of function 
indicative of gastric neuroses also occur as secondary or symptomatic 
conditions of the various diseases of the stomach and of parts in its 
vicinity, especially the biliary tract and the pancreas. They are direct 
symptoms in diseases of the central nervous system, both of the brain and 
of the cord, and reflex phenomena in diseases of the pelvis, and perhaps 
from intestinal parasites. They are of frequent occurrence in acute and 
chronic infectious diseases, in anaemia, ursemia, gout, and diabetes, and 
in consequence of the abuse of tea, coffee, alcohol, and tobacco. They are 
indicative of the toxic action of various drugs, as opium, quinine, and 
digitalis. The especial neuroses may be mild or severe, may occur alone 
or associated with others, and may produce slight or severe disturbance 
of nutrition. The patients, therefore, are either pale, thin, and weak in 
mind and body or stout and strong. When the mind is diverted or 
the patient is alone or in a state of rest the symptoms frequently dis- 
appear, to return when the patient is in company of other persons or 
is overworked or depressed. Important as suggesting the neurotic char- 
acter of the gastric disturbance is the tendency of the patient to exag- 
gerate it. The expression of suffering from gastralgia is extreme. Belch- 
ing is vehement, regurgitation is constant, and vomiting is frequent and 
easy. The recognition of a gastric neurosis is essentially based upon the 
knowledge of the origin of a symptom, since in the one person the dis- 
turbance of function is a sign of disease in the stomach or elsewhere, 
and in the other there is no satisfactory evidence of such disease. 

Gastric neuroses are usually divided into disturbances of sensation, 
motion, and secretion, and in general represent an excessive or defective 
exercise of the function concerned. 

Neuroses of Sensation. — Loss of appetite, anorexia, acoria (loss of 
the feeling of satiety), and liyperorexia, excessive appetite, when not 
symptomatic of other disease, represent gastric neuroses which may be 
excited by emotional disturbances or occur as a simple manifestation of 

54 



850 



DISEASES OF THE DIGESTIVE APPARATUS. 



neurasthenia. Under hyperorexia are to be included bulimia and poly- 
phagia, both terms indicative of an intense appetite. In bulimia the attack 
is paroxysmal, associated with burning pain referred to the stomach, is 
often associated with headache and a sensation of faintness, and is re- 
lieved by food. Polyphagia is permanent and unaccompanied by sensa- 
tions of weakness. Boas applies the term gastralgokenosis to paroxysms 
of gastric pain occurring when the stomach is empty but which are easily 
relieved by food. Parorexia or pica represents the craving for unnatural, 
impossible, or disgusting articles of food, as dirt, chalk, and slate-pencils, 
and includes both the various longings of pregnant women and the copro- 
phagy of the insane and hysterical. 

Hypersesthesia. — This term is applied to the occurrence of a sense 
of discomfort or pain provoked by food and frequently continuing for a 
long period of time. Paroxysmal attacks of epigastric pain independent 
of food are called gastralgia, or, when mild, gastrodynia, and are regarded 
as a neuralgia of the pneumogastric nerves. The paroxysms occur inde- 
pendently of food. The pain is often intense, may extend into the back, 
is somewhat relieved by pressure, is often associated with a sense of 
substernal constriction, and may end in spasms or a condition of semi- 
consciousness. Severe attacks may last for several hours unless relief is 
afforded. 

Treatment. — For the relief of gastralgia, hypodermic injections of 
morphine are often required ; but hydrocyanic acid in dose of three 
drops is sometimes efficient. When the attacks are frequent and per- 
sistent, the epigastrium may be blistered. When they are periodical, 
antiperiodic doses of quinine may be used. Antipyrin in full dose is 
especially useful when the gastralgia is due to a spinal sclerosis. 

Neuroses of Motility. — Increased peristalsis as a motor neurosis is 
shown by eructation, rumination, habitual vomiting, cramps, and peri- 
staltic unrest. Deficient peristalsis as a neurosis occurs in atony of the 
stomach and incompetency of the pylorus. 

Eructation is to be regarded as a neurosis when air is swallowed in 
large quantity, aerophagy, and expelled from the stomach often with a 
loud noise. The air may be swallowed in such quantity as to cause dis- 
tention of the stomach and the production of epigastric distress, palpita- 
tion, and anxiety. 

Regurgitation in its most frequent form is represented by pyrosis, the 
entrance of the acid contents of the stomach into the oesophagus and 
mouth as a hot, thin fluid, often setting the teeth on edge. In rumination, 
or merycism, which is a rare motor neurosis, mouthfuls of food are forced 
from the stomach and again swallowed. The condition may exist for 
years without other disturbance of digestion, and the general nutrition 
suffer but little. 

In habitual or nervous vomiting, which occurs both in children and in 
adults, a part or all of the contents of the stomach are easily and quickly 



DISEASES OF THE STOMACH. 



851 



expelled without preliminary nausea and independently of the quality 
of the food or of the stage of digestion. They are but little irritating if 
expelled soon after eating, but are acid at the height of digestion. In 
this neurosis longer or shorter intervals of freedom from vomiting occur, 
and, as a rule, the health of the individual is not seriously impaired. Ex- 
ceptionally, especially in the hyperemesis of pregnancy, nervous vomiting 
may prove a source of progressive emaciation and debility and possibly a 
cause of death. Leyden has described the occurrence of periodical vomit- 
ing in persons free from other evidence of disease, and it is not infrequent 
as a reflex neurosis in menstruating women. The presence of blood in the 
periodical vomiting of the latter is to be doubted, as is also the assertion 
of the vomiting of the contents of the large intestine by hysterical or 
neurasthenic patients. 

Spasm or cramp of the stomach may affect the stomach as a whole or 
be limited to either orifice. Cramp of the entire stomach is seen in the 
peristaltic unrest described by Kussmaul. In this condition the patient 
complains of distress from muscular contractions of the stomach, which 
are usually associated with borborygmus and splashing and cause mental 
distress to the patient, perhaps compelling her to lead a secluded life. 
The peristalsis is often visible when the stomach is prolapsed. In gen- 
eral, however, visible gastric peristalsis is the result of compensatory 
hypertrophy of the wall in stricture of the pylorus. Leo has observed in 
several instances hypermotility of the stomach causing an early expulsion 
of its contents, as shown by the examination after the use of test meals. 
The effect is essentially that of incompetency of the pylorus. 

Spasm at the oesophageal end of the stomach is not to be discriminated 
from spasm at the lower end of the oesophagus. In each there are a sense 
of deep-seated obstruction in the vicinity of the lower end of the sternum, 
to be overcome by the passage of a full-sized sound, and the regurgitation 
of a tasteless, watery, sometimes frothy fluid. Spasm of the pylorus as a 
pure neurosis is with difficulty to be recognized. If it exists, the symp- 
toms and signs would be those of atony of the stomach long preceded or 
accompanied by frequent attacks of localized pain and resistance in the 
region of the pylorus. 

Atony of the stomach, though often the result of organic disease of the 
wall, may occur as a neurosis. It is manifested by diminished motility, in 
consequence of which the food is unduly retained in the stomach, which 
is distended temporarily, and is always in danger of becoming perma- 
nently dilated. There is a sense of fulness and weight in the epigas- 
trium, and the use of a test meal shows that although the stomach is empty 
before breakfast it contains food three hours after Ewald's break last and 
seven hours after Leube's meal. The impaired motility is also to be 
determined by means of salol, as stated on page 822, and if present may 
delay the elimination of the salol for two days. 

Pyloric incompetency is stated by Ebstein to occur as a neurosis ; it 



852 



DISEASES OF THE DIGESTIVE APPARATUS. 



permits the undigested contents of the stomach to enter the intestine pre- 
maturely, in consequence of which diarrhoea is likely to take place. In- 
competency of the pylorus allows also the regurgitation into the stomach 
of the contents of the duodenum. The diagnosis is to be made by the 
visible passage of air or gas into the intestine when the stomach is 
inflated. 

Neuroses of Secretion. — Super acidity, hyperacidity, and peracidity are 
terms applied to an increase of the hydrochloric acid of the gastric con- 
tents occasioned by the presence of food. The increase of the acid secre- 
tion from the stomach may also continue while the stomach is empty, 
either continuously or periodically. The periodical supersecretion is 
designated by Eossbach gastroxynsis. Superacidity causes diffused pain 
and tenderness in the epigastrium, nausea, pyrosis, and acid vomiting, 
associated in supersecretion with severe headache. Eelief to the symp- 
toms is often caused immediately by vomiting or by neutralizing the ex- 
cessive acidity of the contents of the stomach. The appetite is unaffected, 
and albuminoids produce less disturbance of digestion than do starchy 
foods. Long-continued superacidity is likely to result in enfeebled mo- 
tility and eventual dilatation, attributable perhaps to the production of 
pyloric spasm by the irritation of the excessively acid contents of the 
stomach. Superacidity is shown by the presence of more than two per 
cent, of hydrochloric acid removed after a test meal, and supersecretion is 
made evident by the constant presence of an ounce or more of gastric 
juice in the stomach which has long been deprived of food. 

The existence of a constant subacidity due to a diminished quantity or 
to lack of hydrochloric acid is of doubtful occurrence as a pure neurosis, 
though frequent in consequence of disease. The contents of the stomach 
even at the height of digestion then show less than one per cent, of free 
hydrochloric acid. 

Treatment. — Acidity of the stomach is to be temporarily relieved 
by the use of sodium bicarbonate, lime water, or ammonia in some form. 
Permanent relief is to be obtained by curing the cause of the acidity. 
The habit of using antacids in excessive dose is easily formed : in such 
doses they are irritant to the gastric mucous membrane. 

NERVOUS DYSPEPSIA. 

Nervous dyspepsia, a term introduced by Leube, denotes the occur- 
rence of more or less complex groupings of the various gastric neu- 
roses above mentioned. It is, therefore, a term of convenience, and its 
use may demand the recognition of as many varieties of nervous dys- 
pepsia as there are gastric neuroses. In Leube' s limitation of the term, 
however, the disturbances are moderate, confined to the act of digestion, 
and those of sensation predominate over the modifications of motion and 
secretion, whereas extreme disturbances of function, whether of sensa- 
tion, secretion, or motion, are regarded as distinct diseases, — namely, gas- 



DISEASES OF THE STOMACH. 



853 



tralgia, superacidity and supersecretion, and nervous vomiting. The 
diagnosis of nervous dyspepsia depends largely upon the elimination of 
organic causes of the symptoms, since a purely nervous dyspepsia is con- 
sidered to be independent of obvious anatomical changes. The appear- 
ance and behavior of the patient are often significant of extreme nervous- 
ness, though prolonged observation may be necessary to determine its 
presence. Although the symptoms resemble most closely those of chronic 
gastritis, they frequently bear no constant relation to the quantity or 
quality of food, and this disease is to be eliminated by the lacking eti- 
ology, the inconstancy of the symptoms, and the absence of mucus in the 
washings from the stomach. Ulcer may be suspected from the apparent 
severity of the gastralgia, and cancer may be suggested when excessive 
emaciation occurs. The positive evidence of these diseases as previously 
described is lacking. ,The prognosis of nervous dyspepsia and of the 
gastric neuroses is favorable for the primary or idiopathic varieties, 
although recurrences are frequent. The prognosis of the secondary 
gastric neurosis is that of the diseases in which they occur as symptoms. 

Treatment. — In the treatment of gastric neuroses and nervous dys- 
pepsia the first principle is attention to the general health of the patient. 
In some cases the atony of the digestive organs is the result of physical 
indolence, and is not to be lessened, except by progressively graduated 
exercise. If there is overwork or overstrain, it is essential to remove it. 
In many cases the dyspepsia is but a local expression of the general ex- 
haustion, under which circumstances the rest-cure is to be carried out 
with a greater or less degree of rigor according to the necessities of the 
individual. When there is hyperacidity in a case of nervous dyspepsia, 
the best clinical results are to be obtained by the treatment laid down 
under Chronic Gastric Catarrh. Even when the gastric disturbances are 
seemingly connected with a general hysteria and constitute a neurosis, if 
there be hyperacidity, with or without epigastric tenderness, the treat- 
ment of gastric catarrh may be essayed. 

In ordinary atonic dyspepsia without excessive acidity the regulation 
of the diet is very similar to that of gastric catarrh. It is essential to 
consult the past experience of the individual, as it is in these cases es- 
pecially that substances not usually digestible are for certain individuals 
the most suitable food. Ice-cold water should never be allowed with or 
shortly after a meal. Hot water often acts as a stomachic, and if taken 
(one tumblerful) fifteen minutes before eating quenches thirst. 

Among medicinal substances the simple bitters with aromatics, espe- 
cially one of the peppers, are efficacious. In mild lack of digestive 
power, such as frequently occurs in convalescents, formula 23 will be 
found effective. In more serious cases formula 27 may be tried. When 
there is much flatulence, intestinal antiseptics, such as strontium sali- 
cylate, naphtol, and carbolic acid, may be of great service. (Formula 28.) 
As constipation is ordinarily the rule, laxatives must be freely used, and 



854 



DISEASES OF THE DIGESTIVE APPARATUS. 



especially must care be taken, by the use of large eneniata, to keep the 
colon completely emptied, so that there shall be no retention of scybala 
or other faeces. 

There is much difference of opinion concerning the value of digestive 
ferments in atonic dyspepsia and other forms of indigestion. The fact 
that along with the ferments other remedies or measures are always used 
for the relief of the dyspepsia makes it very difficult to decide what part 
the ferments play in the relief of the patient, but our experience has not 
led us to attach much value to their influence ; nevertheless, the enormous 
quantities of them which are sold indicate that very many practitioners 
are of a different opinion, and, as the ferments are harmless, they may 
well be used as an addition to other treatment. If employed, they should 
be given much more freely than is usually done. The pure pepsin of the 
United States Pharmacopoeia (not the saccharated) should be selected; 
five grains should be given in the middle of the meal and five grains 
immediately upon completion of the meal, an amount equal to one hun- 
dred grains of the saccharated or ordinary pepsin. Pancreatin acts only 
in an alkaline solution, and any effect which it has when given by the 
mouth must be due to its escape into the intestinal tract. 



DISEASES OF THE INTESTINE. 



855 



CHAPTER III. 

DISEASES OF THE INTESTINE. 
ENTEROPTOSIS. 

Definition. — Falling of the intestine. 

Prolapse of the intestine occurs not infrequently in the visceral pro- 
lapse, splanchnoptosis, to which Glenard has directed especial attention. 
As in the prolapsed stomach, wandering spleen or liver, movable kidney, 
or displaced uterus, the abnormality is usually found in women accus- 
tomed to tight lacing, repeated pregnancies, or muscular strain. Both 
small and large intestines may become prolapsed, the coils of the small 
intestine lying largely in the lower part of the abdomen and pelvis. 
Prolapse of the colon (coloptosis) is more frequently observed, the freely 
movable transverse colon being the portion which is oftenest displaced. 
It may become elongated and tortuous, and be S- or M-shaped, the most 
dependent portion lying at the symphysis pubis. 

Prolapse of the small intestine produces no symptoms, except those 
mentioned in connection with gastroptosis. Prolapse of the large intes- 
tine may cause constipation, flatulence, and colic. GUenard asserts that 
the transverse colon can be felt as a cord in the upper part of the abdo- 
men. Boas and Ewald believe that this palpable cord is the pancreas. 
The symptoms associated with enteroptosis are more especially referable 
to the stomach, kidney, spleen, uterus, and the nervous system, and 
those referable to the intestine are either overlooked or attributed to 
disturbance of gastric digestion. 

HEMORRHAGE. 

Bleeding frequently takes place from the blood-vessels of the intestine, 
and when sufficient to cause bloody stools becomes a symptom of marked 
importance. 

Etiology and Appearances. — The hemorrhage is the result of gen- 
eral and of local causes. Among the former are the various diseases 
of the blood, constitutional affections, and infectious diseases. Closely 
allied are the hemorrhages which occur in jaundice and in phosphorus 
poisoning. Among the local causes of intestinal hemorrhage are super- 
ficial lesions, especially the various forms of ulcer, polypus, and cancer. 
In this series are to be included the hemorrhages due to traumatism, 
to intussusception, and to intestinal parasites. Important also is ob- 
struction to the venous circulation, as in fibrous hepatitis, portal throm- 
bosis, valvular disease of the heart, and pulmonary emphysema. Dilated 
veins, especially in the rectum, aneurism, particularly of the aorta or 



856 



DISEASES OF THE DIGESTIVE APPARATUS. 



its primary branches, and embolism and thrombosis of the mesenteric 
vessels are also causes. Nothnagel has called attention to the occur- 
rence in phthisis of intestinal hemorrhage not dependent upon intes- 
tinal ulcers, and Grainger Stewart attributes certain cases of intestinal 
hemorrhage to amyloid degeneration. The most frequent causes are 
hemorrhoids, inflammation and cancer of the large intestine, and typhoid 
fever. 

The appearances presented by the blood vary according to the quan- 
tity, the rapidity of the hemorrhage, the source, and the length of time 
occupied in passing through the intestine. Frequently hemorrhage is 
so slight as to be recognized only with the aid of the microscope, by 
which blood-corpuscles and blood- crystals are distinguished. The more 
abundant and the more rapid the hemorrhage the more likely is the 
blood to appear in clots, which may protrude several inches from the 
anus. The more gradual the bleeding the more constantly is the blood 
mixed with fseces, and the mixture is more intimate the higher up in the 
intestine the source of the bleeding. The less active the peristalsis the 
longer is the blood retained in the intestine, and the more likely is it 
to be of a dark color and relatively firm consistency. A dark, tarry 
appearance of the stools is suggestive of hemorrhage from ulcer of the 
duodenum. 

Hemorrhage from affections of the mesenteric blood-vessels requires 
especial mention, and the publications of Elliot and Watson form an 
important contribution to our knowledge of the subject. The mesen- 
teric artery — usually the superior — may become obstructed by an em- 
bolus which arises from a diseased aortic or mitral valve, or from a 
parietal thrombus of the left ventricle or auricle, or from a thrombus 
of the aorta, or from an aneurism of this artery. More rarely throm- 
bosis of the mesenteric artery" occurs in consequence of arterio-sclerosis. 
Thrombosis of the superior mesenteric vein is less frequent than is embo- 
lism of the corresponding artery, and may be caused by a twist of the 
intestine or by the strangulation of a hernia. We have seen it follow 
embolism of the splenic artery, being continued from a secondary throm- 
bosis of the splenic vein. In certain cases no satisfactory explanation 
for its origin exists. The effect upon the" intestine is the same in both 
thrombosis and embolism of these vessels. The slowness of the cir- 
culation in the mesenteric artery is such that obstruction of the trunk 
causes a hemorrhagic infarction of the part supplied, as in the case of a 
terminal artery, and] the wall of more or less of the small intestine is 
thickened and of a purple color, the contents of the intestine being 
largely bloody. The longer the infarction has existed the more likely 
are necrosis and gangrene to occur. In the last event peritonitis results, 
and a bloody exudation is found in the abdominal cavity. 

Watson, from the study of a collection of twenty-seven cases of embo- 
lism of the superior mesenteric artery, finds that the first symptom of this 



DISEASES OF THE INTESTINE. 



857 



lesion is usually a violent abdominal pain, not sharply defined, and often 
associated with vomiting and diarrhoea. The stools were bloody in one- 
half the cases, and the temperature was subnormal in one-third. The 
stools are at times of a tarry character, and the affected portion of the 
intestine may be distinctly resistant on palpation. The patient may die 
within twenty-four hours after the onset of the symptoms, or may live 
nearly a fortnight. If the patient survive the immediate effects of the 
embolism, symptoms of peritonitis are likely to occur in the course of 
two or three days. 

The diagnosis is based upon the occurrence of a sudden abdominal 
pain associated with vomiting, diarrhoea, bloody stools, and subnormal 
temperature in an elderly person previously well or having a history of 
antecedent embolism and presenting evidence of valvular endocarditis 
or of arterio-sclerosis, or in a person suffering from acute rheumatism. 
Other sources of the sudden pain and intestinal hemorrhage are to be 
excluded when possible. 

Oases of embolism of the mesenteric artery have so constantly proved 
fatal that the prognosis has been recognized as of the gravest nature, 
although in rare instances spontaneous recovery has taken place. Elliot 
has shown that surgical treatment of this lesion may prove efficacious, a 
patient from whom he removed four feet of the intestine in a state of 
infarction having recovered. 

Treatment. — The treatment of hemorrhage from the small intes- 
tine has been sufficiently described in the article on Typhoid Fever. 
(See page 143.) When the blood comes from the large intestine, efforts 
should be made to arrest its flow by local measures. Ice- water injections, 
or ice itself, may be introduced into the large intestine ; or astringent 
injections may be employed, especially the injection of a drachm of silver 
nitrate in two quarts of water. If there be reason to suspect mesenteric 
embolism, a surgical consultation should be held, and, if circumstances 
favor, laparotomy may be performed. 

Hemorrhage from the rectum must be treated locally. 

ENTERITIS. 

Definition. — Inflammation of the bowels. 

Inflammation of the intestine is characterized by the appearance of an 
exudation within its wall, upon its surface, or in both situations, and 
pursues an acute or a chronic course. It is often confounded with diar- 
rhoea, since the causes of each are largely the same, and diarrhoea — 
frequent loose dejections — is the conspicuous symptom of enteritis. 
Diarrhoea, however, represents largely an increase of intestinal peri- 
stalsis, especially of the colon, in which the intestinal contents remain 
normally from twelve to twenty hours. The increased peristalsis is 
due not only to the action of irritants, but also to peculiarities of the 
individual. Two or three movements daily are physiological for some 



858 



DISEASES OF THE DIGESTIVE APPARATUS . 



persons, and an unusually sensitive nervous system often so reacts to 
mental or bodily excitants that diarrhoea results. 

Etiology. — The principal causes of acute enteritis are to be included 
under irritation and infection, although the latter usually acts by means 
of the irritation produced by its products. Conspicuous among the irri- 
tating causes are improper food and drink. The food may be improper 
in consequence of its nature, as unripe fruit, or from putrefactive or fer- 
mentative changes such as occur in spoiled meat, fish, fruit, and vegetables, 
or from excess in quantity or bad cookery. In like manner, milk and 
milk products may be so altered by the growth of bacteria as to excite 
enteritis. Various chemical irritants, many of them medicinal in suitable 
dose, as arsenic, antimony, and mercury, produce enteritis when their 
action is intensified. Foreign bodies, especially when serving as the 
nuclei of fsecal concretions, may be productive of inflammation. 

The infectious causes of enteritis are those giving rise to cholera, 
cholera nostras, cholera infantum, and dysentery, in which the enteritis 
is to be regarded as primary. In typhoid fever, pneumonia, tuberculosis, 
measles, septic infections, and peritonitis a secondary or symptomatic 
enteritis is frequent. Acute enteritis also may result from injury, in- 
cluding that due to severe burns. It occurs in the course of nephritis, 
tuberculosis, diabetes, and other chronic affections. Children, especially 
infants, are more frequently affected with acute enteritis than adults, 
largely in consequence of unclean feeding-bottles and of improper food. 
The prevalence of enteritis in summer is largely due to the favoring in- 
fluence of heat in the production of putrefaction and fermentation. Im- 
portance is often assigned to exposure to cold as a cause of enteritis, 
but its influence is to be regarded, like that of heat, rather as predis- 
posing and aiding than as actually producing the inflammation. 

Varieties. — The anatomical varieties of enteritis are the catarrhal, 
follicular, pseudo- membranous, ulcerative, diphtheritic, phlegmonous, 
and gangrenous. The lesions are circumscribed or diffuse, and, accord- 
ing to the part of the intestine affected, a distinction is drawn between 
duodenitis, jejunitis, ileitis, appendicitis, typhlitis, colitis, and proctitis. 
Such a distinction, however, is practicable for only certain portions of the 
intestine ; for example, inflammation of the stomach and inflammation of 
the duodenum are frequently combined, and the disease is regarded as gas- 
tro- duodenitis or gastro- duodenal catarrh. Inflammation of the jejunum 
presents no characteristics by which it is to be differentiated from inflam- 
mation of the ileum, and the entire small intestine is often simulta- 
neously diseased ; hence enteritis or ileitis is commonly used to designate 
inflammation of the small intestine, irrespective of the part conspicuously 
diseased. In like manner colitis is applied to inflammation of the colon 
although inflammation of the rectum (proctitis) and inflammation of 
the csecuni (typhlitis) may be associated. Inflammation of the csecuni 
rarely occurs as an independent condition ; and although the term typhlitis 



DISEASES OF THE INTESTINE. 



859 



was originally applied to indicate what was supposed to be an inflamma- 
tion of the csecum, the symptoms of typhlitis are now known to be almost 
invariably the result of appendicitis, or inflammation of the vermiform 
appendix. Inflammation of the rectum not infrequently occurs without 
associated inflammation of the colon, although often combined with it. 
Most important of all the localized inflammations of the intestine is that 
of the appendix, designated appendicitis. When the inflammation exists 
throughout the large and the small intestine the term entero- colitis or 
ileo- colitis is applied. 

ACUTE CATARRHAL ENTERITIS. 

Morbid Anatomy. — The changes due to acute catarrhal inflam- 
mation of the intestine are redness and swelling of the mucous mem- 
brane, with increased secretion. Post-mortem changes produce such 
alterations in the distribution of blood in the vessels of the intestine 
that but little importance can be attached to redness as a sign of inflam- 
mation unless it is caused by extravasated blood. More important is the 
swelling of the mucous membrane, chiefly due to oedema, and especially 
noticeable in the valvulse conniventes in the upper part of the large 
intestine. In severe acute enteritis coherent flakes of epithelium are 
detached and abundantly appear in the liquid contents of the intestine, 
forming the rice-water stools of choleraic enteritis. The presence of any 
considerable quantity of mucus is rare in acute inflammation of the small 
intestine, although a somewhat opaque, perhaps blood-stained, mucus is 
often found in acute catarrhal colitis or proctitis. In follicular enteritis 
there is swelling of the solitary follicles and Peyer's patches, the indi- 
vidual follicles being surrounded by injected blood-vessels. The follicles 
are either translucent or opaque, and in severe cases become transformed 
into abscesses, which break and give rise to ulcers. 

Symptoms. — Diarrhoea is the conspicuous symptom of enteritis, al- 
though frequent loose movements of the bowels may occur in the absence 
of inflammation, and enteritis may exist without diarrhoea being present. 
The number of dejections varies from three or four to twenty and up- 
ward in the course of the twenty-four hours, and the quantity of the 
movement diminishes with the increase in the number of dejections. 
They contain abundant liquid, either as a result of diminished absorp- 
tion from increased peristalsis or in consequence of serous exudation 
from the wall of the intestine. They are either homogeneous or con- 
tain particles of undigested food, milk-curds being frequently recog- 
nized. The color of the evacuation depends upon the quantity of bile 
or blood present and the changes undergone by their pigment. The 
absence of bile gives rise to a colorless or clay-colored dejection, while 
grass-green stools result from the rapid passage of the bile through the 
intestinal canal. With less frequent movements the color is yellow or 
yellowish brown. In simple catarrhal enteritis the presence of blood in 



860 



DISEASES OF THE DIGESTIVE APPARATUS. 



the stools is rare. The color is also modified by the nature of the food, 
being of a lighter hue from a milk diet and of a darker tint when meat- 
juice is taken. The effect of medicines, especially of bismuth and iron, 
in blackening the stools is a familiar fact. The consistency of the evacu- 
ations varies from that of a thin watery to that of a soft pudding-like 
material, and, in general, the more frequent the evacuations the thinner 
is the consistency likely to be. The dejections are not infrequently frothy, 
from the intimate admixture of bubbles of gas. Mucus is a more constant 
characteristic of chronic than of acute enteritis, and when present in the 
latter is usually the result of the presence of the inflammation in the 
large intestine, in which case the mucus may be blood-stained. The reac- 
tion of the stools is generally alkaline, and on microscopical examination, 
particles of undigested food, epithelial cells, mucous corpuscles, bacteria, 
and often various crystals are to be found. When parasites are suspected 
as the cause of the enteritis, search should be made for them and for the 
eggs. 

Abdominal pain is frequent, usually of a spasmodic character, and 
often associated with rumbling borborygmus as gas or a mixture of gas 
and liquid is moved along the course of the intestine. The pain is 
usually referred to the lower abdomen, and, when the large intestine is 
the seat of the inflammation, may follow the course of the colon or be 
referred to the region of the sigmoid flexure. The presence of tenesmus 
is indicative of the seat of the inflammation in the rectum. In the 
milder cases there is no fever, but in the severer forms of enteritis, 
especially those of infectious origin, slight or severe chills early occur, 
and the temperature is elevated two or three degrees. In the severe 
attacks loss of appetite, thirst, nausea, and vomiting are usually present, 
but they may be absent. The strength of the patient may be so little 
disturbed that he is capable of pursuing his daily occupation, or there 
may be so much weakness and prostration that he is confined to the bed 
and suffers from symptoms of collapse. 

The abdomen is either distended, usually moderately, or flattened, 
according to the presence of a greater or less quantity of gas and the 
frequency of the dejections. Tenderness is present only in the severer 
cases, especially when the inflammation is limited to the colon. Albu- 
minuria and casts have been found in severe cases of acute enteritis, 
and enlargement of the spleen has been observed. The duration of the 
attack varies from a few days to a fortnight, or the enteritis may become 
chronic ; irregularity in the action of the bowels for weeks or months 
is a frequent result. 

The acute enteritis of infants has an enormous mortality, especially in 
the su mm er among the children of the poor in cities. As already stated, 
this variety is largely due to the use of unclean feeding-bottles, in con- 
sequence of which putrefaction or fermentation of the intestinal contents 
takes place. The diarrhoea is associated with vomiting. Convulsions 



DISEASES OF THE INTESTINE. 



861 



are at times present, there is considerable elevation of temperature, 
the child frequently cries from paroxysms of colic, and the abdomen is 
swollen and painful. The dejections are often of a greenish color, frothy, 
and contain abundant curds. This variety of acute enteritis may be 
soon recovered from or may gradually prove fatal from exhaustion. It, 
however, may give evidence of involvement of the colon (entero- colitis). 
In this event the stools are more faecal in character, but contain abun- 
dant mucus, often stained with blood, and the attack pursues the course 
described under Dysentery. (See page 215.) 

The severest variety of acute enteritis in children is known as cholera 
infantum. The vomiting and diarrhoea are excessive, the dejections rap- 
idly become watery, and a condition of collapse readily supervenes. 
The incipient abdominal pain soon ceases, but painful cramps in the mus- 
cles of the extremities may take place. The superficial temperature is 
often subnormal, although the thermometer in the rectum indicates the 
presence of fever, and there may be hyperpyrexia shortly before death. 
The infant lies still and indifferent, the face is pinched, the fontanelles are 
sunken, the skin is cool and moist, the pulse is small and rapid, and in 
fatal cases death occurs suddenly, perhaps after a convulsion, or gradually 
at the end of prolonged coma. The prognosis in cholera infantum is 
always grave, and death may occur within forty-eight hours after the 
attack, or at the end of a few days. In cases of recovery convalescence 
is usually protracted over a period of several weeks. 

Diagnosis. — The distinction between simple diarrhoea and enteritis 
is essentially one of degree. Both may be due to the same causes, but 
the difference in result is dependent upon the intensity of the irritant, 
the persistence of its action, and the degree of vulnerability of the 
patient. In diarrhoea the cause of the increased peristalsis is quickly 
eliminated, in enteritis it persists. Diarrhoea may be caused by emo- 
tional excitement, and merely represents increased peristalsis and con- 
sequent defective absorption, the degree of which often varies in indi- 
viduals. The clinical diagnosis of enteritis demands the presence of 
diarrhoea in connection with one or more of the cardinal symptoms of 
inflammation. The character of the stools offers evidence as to the pre- 
dominant seat of the inflammation in the large or in the small intestine. 
In enteritis as contrasted with colitis the dejections are more watery, 
yellow or green, and a sediment forms on standing. In colitis, on the 
contrary, the dejections are more homogeneous, and contain ftecal matter, 
either in scybala or flakes, and easily differentiated particles of mucus. 
Vomiting is a more frequent accompaniment of enteritis, abdominal 
pain is more frequent in colitis, and tenesmus is the characteristic of 
proctitis. An excess of indican in the urine in enteritis is indicative 
of a localization of the inflammation rather in the small than in the large 
intestine. 

Treatment. — Acute diarrhoea dependent upon enteric irritation 



862 



DISEASES OF THE DIGESTIVE APPARATUS. 



should be treated as acute enteritis, and all irritating or actively astrin- 
gent drugs are contra-indicated. On the other hand, the sudden diar- 
rhoea of summer, attended with colicky pain, without tenderness, and with 
free serous discharges, and the paroxysms of serous purging without 
pain which are often induced by anxiety or other emotions, are usually 
to be relieved by stimulating prescriptions containing camphor, chloro- 
form, and volatile oils, with or without opium. (See formula 9.) In 
many of these cases, especially when there is no emotional disturbance 
and the discharges are very large, watery, and free from color, no remedy 
will compare in therapeutic activity with mercurials : from one-eighth 
to one-sixth of a grain of calomel should be given every hour until the 
passages become greenish or brownish ; very commonly when this has 
happened the diarrhoea ceases spontaneously ; if this does not occur, 
astringent or stimulating local remedies may be expected to act imme- 
diately. (See also Cholera Nostras.) 

In serous diarrhoeas all active exercise should be avoided ; indeed, 
if the symptoms be severe, the patient should be put to bed. Care 
should be taken to protect the abdomen from r cold. The food should be 
reduced to broths or milk foods. Sometimes partially predigested milk, 
in the form either of ordinary peptonized milk or of junket, is very suit- 
able. Milk thickened with flour and thoroughly cooked has in our ex- 
perience acted better than milk thickened with arrow-root or other 
starches formerly recognized by the United States Pharmacopoeia. An 
excellent food which is very binding is made by filling a pint bag tightly 
with flour, sewing it up, throwing it into boiling water, and after five 
or six hours of cooking taking out the contents, cutting off the outer 
sodden rind and grating the inner baked core, and then incorporating 
the gratings with very hot milk. 

The treatment in acute enteritis must vary in its rigor with the 
severity of the disease. In pronounced cases the patient should be put 
to bed and confined to a diet composed of animal broths, milk, and 
milk foods. (See above. ) In milder cases tender meats may be allowed, 
but broken or ground grains and vegetables are to be forbidden. Eube- 
facients often distinctly relieve pain, and are to be freely used. In bad 
cases a poultice containing from ten to twenty per cent, of mustard 
should be placed over the whole abdomen, or the spice plaster be used. 
As a substitute for the latter, spongiopiline, or a cloth, may be wrung 
out of a tincture made by macerating one ounce each of Cayenne pepper, 
cloves, and allspice in a pint of alcohol ; the cloth may be covered with 
oil-silk, and is often preferred to the poultice on account of its light- 
ness. A flannel bandage should be worn both day and night when 
there is no other local application to the abdomen. Hot- water bags are 
often very comforting. 

In the beginning of the attack, especially if the passages are small 
and contain abundant mucus or if there is a history of the recent inges- 



DISEASES OF THE INTESTINE. 



863 



tion of indigestible food, a full dose of castor oil and laudanum may be 
given, or one-fourth to one-sixth of a grain of calomel may be adminis- 
tered every two hours until free bilious discharges are produced. A mix- 
ture of equal parts of castor oil and aromatic syrup of rhubarb (U.S. P. 
1880) given in small doses every hour sometimes acts most happily. 
After the purgatives have acted, a mixture of bismuth and carbolic acid 
(see formula 5) should be exhibited ; with it may be combined, as a 
slightly astringent antacid, simple prepared chalk. When with the con- 
tinuing diarrhoea there are persistent tenderness and no improvement 
under the use of bismuth and carbolic acid, silver nitrate with extract 
of opium or of hyoscyamus may be given in pill covered with a thick 
capsule. Salol is often advantageous as a sedative to the intestinal 
mucous membrane and as an intestinal antiseptic. When there are 
marked evidences of fermentation, or when there is much flatulence, 
naphtol (two grains) or strontium salicylate (three to five grains) may 
often be combined advantageously with the bismuth and carbolic acid. 

The diarrhoea which exists in enteritis seems naturally to indicate 
the use of astringents, and when the discharges are very free this ap- 
parent indication grows correspondingly in force. It must, however, 
be remembered that all vegetable astringents are irritant, and that the 
discharge from the bowels which is provoked by inflammation usually 
does more good by relieving the local disease than it does harm by ex- 
hausting the patient. The effort of the practitioner should be to cure 
the condition which provokes the diarrhoea, and not to arrest the diar- 
rhoea. If an astringent seems to be necessary to control excessive diar- 
rhoea, lead acetate is more sedative and less irritant than the vegetable 
astringents. In the latter stage of the disease the condition of the in- 
testines may be one of relaxation following acute congestion and inflam- 
mation, so that an astringent is really indicated: under these circum- 
stances the sulphuric acid mixture (formula 6) will usually be found to 
act happily, or the chalk mixture (formula 8) may be tried. 

Treatment of Acute Diarrhoea of Young Children. 
The acute diarrhoea of childhood is for therapeutic purposes divisible 
into two classes of cases, — those which are typified in acute enteritis and 
those which are typified in an acute cholera infantum ; the one with 
small mucous discharges, the other with large serous passages. We think 
every practitioner who has seen much of infantile diseases will recognize 
that the line between the cases, considered as a whole, is not sharp, but 
that the two typical forms grade into each other. Nor yet, in accord- 
ance with our experience, is the etiological difference in the two classes 
absolutely diverse. The typical cholera infantum and the typical entero- 
colitis of the child may be produced in different children by similar 
causes. In the summer the chief cause of severe and fatal diarrhoea 
among young children is elevation of temperature. The mortality -curve 



864 



DISEASES OF THE DIGESTIVE APPARATUS. 



among children in onr great cities closely follows the temperature-curve ; 
the rise of temperature to 100° F. at mid-day, continuing for several 
days, always being soon followed by a rise in the mortality-rate. 

It is evident, further, that the eating of improper food, sour milk, 
bad fruits, stale vegetables, fermented and altered by heat, is a fruitful 
cause of the summer diarrhoea of children, and that an increase of the 
general temperature, by increasing the activity of change in animal and 
vegetable foods, augments the danger to the poor of great cities of bowel 
complaints from improper ingesta. 

In the clear recognition of the vitality of these two etiological facts 
lies, we believe, the secret of the proper management of the acute in- 
fantile diarrhoeas under consideration. If the disease occurs during the 
hot spell, and the temperature of the child is above the normal, the 
reduction of the temperature by the cold-water or cold-air bath affords 
the one rational method of treatment. The temperature of the young 
child should always be taken in the rectum, as the internal temperature 
may be very high at a time when the external or axillary temperature 
is comparatively low. Again, the sudden unconsciousness, with disturbed 
respiration and other evidences of cerebral paralysis, which frequently 
ends the scene in cholera infantum in the summer months, is due to 
hyperthermia. Early reduction of the temperature by the use of cold in 
such cases is followed by immediate improvement of the nervous symp- 
toms. Peevishness and prostration during the day, with intense restless- 
ness at night and convulsive startings, are often put an end to by cold 
bathing. The bath should be repeated every two to four hours, should be 
at a temperature of 90° F., cooled to 80° F. if necessary, and should be suf- 
ficiently prolonged to reduce the temperature. From time immemorial 
the effects of change of air in the treatment of cholera infantum obtained 
by taking the child to the sea-shore or over some large body of water 
have been considered most remarkable. The effects reached have really 
been due more to change of temperature than to change of air, and are 
not, therefore, so mysterious. Steady cooling by constant immersion in 
cool air is, of course, when obtainable, to be preferred ; but intermit- 
tent cooling by occasional immersion in cool water is often the best that 
can be obtained. When the cholera infantum patient can be sent to the 
sea- shore it should be done ; but probably the shaded country spring- 
house would be nearly as effective as the cool sea-breezes. An electric fan 
forcing air over suspended blankets kept continually wet we have known 
apparently to save life when a fevered patient could not be taken out 
of the heat. The hydrencephaloid congeries of symptoms with which 
is especially associated the name of Marshall Hall are in some cases of 
infantile diarrhoea the outcome of exhaustion, to be met by stimulants 
and concentrated digestible foods. As they occur, however, in children 
in American cities during summer months, they are usually the result 
of hyperthermia. Whenever the temperature reaches 101° F. the child 



DISEASES OF THE INTESTINE. 



865 



should be bathed in tepid water ; at 102° F. cool bathing is urgently 
needed ; at higher temperatures failure to use the bath is a crime. The 
rise of the bodily temperature in these cases is no more due to inflam- 
mation or a measure of the severity of the intestinal irritation than is 
the high temperature of a stevedore who falls sunstruck on the wharf 
where he labors. Large injections of ice-cold water are very serviceable, 
acting locally well and aiding in reducing the general temperature. 

As in many cases of acute diarrhoea occurring in the young child the 
intestines contain a fermenting mass of undigested food and disordered 
secretion, it is commonly well to commence the treatment by a full dose 
of castor oil or a mixture of equal parts of castor oil and spiced syrup 
of rhubarb. When the passages are very large and serous the purgation 
may be omitted. Small doses of calomel (one-twelfth to one-eighth of 
a grain) may be given every two hours, with or without three to five 
grains of bismuth subnitrate, according' as the practitioner believes that 
the attack is or is not accompanied with pronounced irritation or in- 
flammation of the mucous membrane. Carbolic acid, by arresting fer- 
mentation and by its anaesthetic influence on the intestines, often acts 
happily when conjoined with the bismuth. The vegetable astringents are 
almost always useless remedies, and frequently do harm. Opium is often 
indispensable, but should be used with the greatest caution, and with the 
full remembrance of the fact that the momentary checking of a symptom 
is not curing the disease. Quinine, strychnine, and all other remedies 
which are capable of irritating the alimentary canal are harmful in most 
of these cases. Drugs like strychnine and digitalis may be used in times 
of collapse, but under such circumstances should be given hypoder- 
mically. Alcohol is often indicated, and, given sparingly in the form 
of fine old brandy, is incapable of doing harm, except it be in those cases 
in which the local inflammation is severe. Salol, naphtol, strontium sali- 
cylate, and other drugs which act as intestinal antiseptics are often of 
service, especially in those cases in which the discharges are not sufficient 
to clear out thoroughly the alimentary canal and in which there is reason 
for believing that fermentation is going on within the intestines. When 
the passages are serous and very large, or when, as in a typical cholera 
infantum, they are apparently paralytic in origin, camphor, chloroform, 
and the volatile oils may be used cautiously as in other forms of nervous 
diarrhoea. 

The feeding of a child suffering from an acute summer diarrhoea is a 
matter of the gravest importance. In severe cases the only thing allowed 
at first should be water rendered albuminous with the white of egg : the 
white of one or two eggs should be thoroughly shaken with a pint of 
water ; in many cases brandy should be added to this solution. Animal 
broths, especially chicken broth, without rice or other farinaceous in- 
gredients, or pure beef -juice obtained by expression, should be the first 
foods given after the albuminous water. Wine whey sometimes acts 

55 



866 



DISEASES OF THE DIGESTIVE APPARATUS. 



well. Milk, if employed at all, should be of absolute purity and fresh- 
ness when possible ; if not, it should be sterilized. Pure milk should be 
partially predigested. Junket is probably superior to simple milk, it 
being, indeed, milk in an early stage of digestion. Not rarely lime 
water may be added to the milk, in the proportion of one to four or 
one to eight, with advantage : by delaying coagulation in the stomach 
it tends to prevent the formation of hard curds. In any case of acute 
intestinal diarrhoea occurring in a breast-fed child there is no food 
superior to the breast-milk, if it be of good quality ; it may be right 
for a few hours to confine the child to the albuminous water, but the 
nursing should not long be interrupted. If, however, as is often the 
case, excessive thirst leads the child to drain the breast too frequently 
and too thoroughly, due caution must be exercised to see that there is no 
overfeeding. 

CHRONIC ENTERITIS. 

Definition.— Chronic inflammation of the mucous membrane of the 
small intestine, very frequently also involving that of the large intestine. 

Chronic enteritis is anatomically divided into chronic catarrhal en- 
teritis, in which the inflammatory change is of the catarrhal type ; 
pseudo-membranous enteritis, in which the inflammation is accompanied 
with the formation of large quantities of mucoid secretion, taking the 
form of membranes or casts ; and ulcerative enteritis, in which the 
formation of ulcers is the conspicuous feature. 

CHRONIC CATARRHAL ENTERITIS. 

Chronic catarrhal enteritis is either the result of acute enteritis or is 
chronic from the outset, in which case inspissated fseces, ulcers, and tumors 
of the intestine, intestinal parasites, chronic passive congestion of the 
portal system, and chronic wasting diseases are important in the etiology. 

Morbid Anatomy. — The mucous membrane is swollen, opaque gray r 
perhaps slate- colored from the presence of modified blood-pigment in the 
interstitial tissue. The pigment often lies in the villi and in the vicinity 
of the follicles. The mucous membrane is thickened from an increase of 
its fibrous tissue, which may be diffused or cause polypoid projections from 
the surface or extend into the submucous and muscular coats. The outlet 
of the glandular crypts may be obstructed and dilatation of the ducts 
result. There is an abundant formation of mucus, especially in the large 
intestine, and it may be copious in the small intestine, in which normally 
little or no accumulated mucus is to be found. Occasionally, especially in 
children, the mucous membrane becomes atrophied and the cryptic glands 
to a large extent are destroyed. 

Symptoms. — In chronic enteritis there is a frequent alternation be- 
tween constipation and diarrhoea. The daily number of loose dejections 
is in the vicinity of half a dozen, and pain may or may not be associated 
with the movements, but the patient often complains of a sense of weight 



DISEASES OF THE INTESTINE. 



867 



and discomfort in the abdomen. The dejections contain abundant mucus, 
and not infrequently a slimy dejection with but little fsecal matter is 
followed by a scybalous movement, or mucus and faeces are intimately 
mixed. When the abdomen is distended and tympanitic, borborygmi 
are often heard. There may be tenderness on palpation. There may 
be but little disturbance of nutrition, or marked emaciation may exist. 
In children there are likely to be extreme emaciation and weakness. 
Adults suffering from chronic enteritis are often irritable or depressed, 
easily fatigued, and frequently hypochondriacal. Chronic enteritis is 
of long duration in the adult, with periods of exacerbation and remis- 
sion, at times prolonged intervals of freedom existing. In young chil- 
dren and in elderly persons it may prove a cause of death from progres- 
sive exhaustion. 

Treatment. — The hygienic management in a case of chronic catar- 
rhal enteritis is extremely important, and must be attended to in the 
minutest details by the practitioner. At no time should any chilling of 
the surface of the body be allowed ; a heavy, well-fitting woollen or silk 
abdominal bandage is vital, and should be worn continually, it being 
changed day and night. A woollen or silk long-sleeved under-vest or 
under-shirt must be worn day and night ; the ankles also should be well 
protected from draughts, the patient on no account being allowed to put 
the naked foot upon even a carpeted floor, and in cool weather shoes 
should be worn instead of slippers even in the house. The drinking must 
be carefully attended to. Ice-cold liquids are to be forbidden, no sweet 
drinks are to be allowed, and wines are in large part to be excluded 
from the dietary. In some cases the stronger wines, such as port and 
madeira, may be given very sparingly • but ordinarily if any alcohol is 
taken it should be in the form of well-diluted spirit, pure brandy being 
usually preferable to whiskey. Coffee should not be taken at all ; tea 
may be used in moderate quantities. Sometimes it is advantageous to 
confine the patient temporarily to a skim-milk diet. In other instances 
it is better to allow Hamburg steaks or broiled or baked tender meats, — 
veal, turkey, pork, and tame duck being absolutely forbidden. Starchy 
foods are rarely allowable ; toast or pulled bread may be given, but 
potatoes and the various farinaceous dishes are contra- indicated. Maca- 
roni stewed in milk without cheese agrees with most cases, and rice may 
be used if necessary to satisfy the craving for vegetables. Generally 
no vegetables should be taken. Custards, and bread and other simple 
plain puddings, without much sugar, are to be put on all except the 
strictest diet- lists. Eggs cooked (not fried) or raw may be given in 
moderate amount. 

The amount of exercise allowed must be carefully suited to the indi- 
vidual case. Not rarely there is pronounced exhaustion, and rest in bed 
with massage is essential. On the other hand, an old enteritis is some- 
times very happily affected by carefully graded exercise. 



868 



DISEASES OF THE DIGESTIVE APPARATUS. 



In most cases the discharges can be temporarily arrested by the use of 
astringent remedies, but this arrest of the diarrhoea is followed rather by 
an increase than by a betterment of the intestinal condition. Astrin- 
gents are not curative, are very capable of doing harm, and when 
largely and actively employed are always an evil. The acid diarrhoea 
mixture (see formula 6) is the most serviceable and least harmful that we 
have ever employed. Guarana, twenty grains an hour after meals, is 
sometimes well borne. Certain astringent or alterative mineral waters, 
especially the Oak Orchard Acid Spring water, and when there is much 
intestinal indigestion the Franzenquelle water of Europe, may be of 
service. In many cases of catarrhal enteritis purgatives are from time 
to time indicated, and complete irrigation of the colon is often very useful. 
Among purgatives the castor oil and glycerin mixture is usually to be 
preferred; occasionally small doses of calomel act well. The enemata 
should be two quarts of simple water, or may often with advantage be 
medicated. Occasionally scybalous masses will be found in the stools 
produced by the enemata, faecal retention being not impossible in chronic 
enteritis ; the entire removal of such bodies from the alimentary canal is 
essential to recovery. In other cases, even when there is considerable 
diarrhoea, black, slimy, mucoid discharges are provoked by the injec- 
tions, so that it would appear as if the large intestine was covered by 
a fermenting mass of old retained secretions and fsecal matter, through 
which ran a central current. In such cases the medicated injections, 
especially the silver nitrate (ten grains to two quarts), should be repeated 
at intervals of from two to six days until the bowel is cleansed. 

For the purpose of directly affecting the inflamed mucous membrane, 
the most effective remedy we know of is the tar- water mixture (see for- 
mula 22) : a wineglassful (a fluidounce and a half) should be given from 
one to two hours after each meal. Silver nitrate is much used, but has 
afforded us little satisfaction ; if given at all it should be in pill enclosed 
in a double capsule, so as to avoid as far as possible its destruction before 
it reaches the intestine. Bismuth, especially bismuth with carbolic acid, 
or the combination of bismuth, naphtol, and carbolic acid, is valuable. 
Other aromatic products than tar, such as turpentine, oil of cubeb, or oil 
of copaiba, may be used in various cases. Any remedy given for the 
purpose of affecting the mucous membrane of the small intestine should 
be taken from one to two hours after eating, at a time when the current 
is naturally setting from the stomach into the intestinal tract. 

Chronic Biarrhcea of Young Children. 
Chronic intestinal catarrh of infancy is in the great majority of cases 
the result of improper feeding, When it occurs in breast-fed infants 
the milk of the woman should always be looked upon with suspicion ; 
although simple irregularity of feeding, and especially excessive frequency 
of feeding, will sometimes derange the digestion of the feeble child. No 



DISEASES OF THE INTESTINE. 



869 



artificial food has as yet been made that compares, in its accord with the 
digestive system of the infant, with human milk j and therefore, when 
chronic catarrh in the bottle-fed child does not yield to careful treatment, 
it may be essential to procure a wet-nurse, even if the proper sustenance 
of the child of the rich parents involve the improper feeding of its less 
fortunate confrere. 

The proper hygiene of the wet-nurse should always be looked after. 
Much harm is often done by, pampering. Accustomed to a life of plain 
food and hard work, the wet-nurse is often overfed, under-exercised, and 
suddenly in every way led into a life of luxurious ease that cannot do 
otherwise than derange her general system. 

It is evident that very many children must be brought up upon arti- 
ficial food. In attempting this the child should, if it be possible, live 
rather in the country than in the town ; good being achieved not only by 
the fresh air and out-door life of the country, but also by the freshness 
and purity of the staple food of infantile life, milk. The most generally 
applicable substitute for human milk is that of the cow, which is usually 
believed by experts to be improved by a process of sterilizing, — heating 
for fifteen to twenty-five minutes at a temperature of 165° F. to 170° P., — 
but which is probably injured by boiling. In our largest cities the attempt 
is being made to furnish to physicians milk which has been modified by 
the subtraction or addition of various substances, so as to render it more 
closely allied in its composition to human milk ; indeed, it is proposed 
that the physician shall order for the individual babe milk of a certain 
composition to suit its especial needs. It is, however, very doubtful 
whether any of these refinements of chemical activity yield products 
which equal absolutely fresh milk obtained by having the cow within 
a few hundred yards of the infant. For the first three months of the 
babe's life the milk should be diluted with two parts of boiled water ; for 
the second three months of life equal parts of boiled water may be added ; 
after this half as much water may be put with the milk ; and after nine 
months the milk can be given undiluted. Excessive dilution sometimes 
leads to curious results, as in a temporarily baffling case in which the 
only symptoms were that the child was constantly crying, constantly 
taking food, and constantly urinating ; the whole difficulty was at last 
found to be the excessive dilution of the milk, which caused the starved 
child to cry and drink from excessive hunger, and to urinate to get rid 
of the water. When any intestinal catarrh refuses to yield to treatment 
whilst the child is being carefully led with cow's milk, artificial foods 
may be tried. Of these the most popular are largely composed of grape- 
sugar. A study of the various artificial foods, sufficiently detailed to be 
of value, would far exceed the limits proper in a volume like the present, 
and the reader is referred especially to works on diseases of children. 

The hygienic management of the child suffering from chronic in- 
testinal catarrh is important. It should be daily bathed in cool — not 



870 



DISEASES OF THE DIGESTIVE APPARATUS. 



cold — water, should in the summer season be protected from the heat 
and in the winter from the cold, and should at all times wear a woollen 
abdominal bandage. 

The medicinal treatment of chronic intestinal catarrh in childhood can 
be outlined in a few words. The most important principle is to avoid all 
astringent remedies as far as possible, and to attempt to cure the catarrh, 
and not the diarrhoea which is its symptom. Mercurials are of value. 
Minute doses of calomel or of gray powder may occasionally be given 
for several days at a time with advantage. Bismuth subnitrate is much 
used, and is often temporarily of value ; very frequently it may be given 
with advantage associated with chalk (five to ten grains of each three to 
four times a day). The intestinal antiseptics are important : salol, creo- 
sote, carbolic acid, naphtol, strontium salicylate, may be used from time 
to time, alone or in combination with bismuth, often very advantageously. 
The one drug, however, which we have seen yield the most beneficial 
results is sodium phosphate ; it is rather laxative than astringent, but 
evidently favorably modifies the intestinal secretions. From five to ten 
grains of it should be given with each bottle of milk or immediately after 
the taking of the food. 

PSEUDO-MEMBRANOUS ENTERITIS. 

This variety of chronic enteritis has been designated also pseudo- 
membranous colitis and mucous colic. It oftenest occurs in neurasthenic 
or hypochondriacal persons, usually in women, and sometimes in chil- 
dren. It is possible that two distinct conditions exist, the one inflam- 
matory, the other a neurosis. The essential characteristic is the dis- 
charge from the intestine of a gray mucus, translucent or opaque, in 
the form of membranes or of cords, sometimes a foot or more in length, 
and of tubular casts of portions of the intestine, often discolored by the 
intestinal contents and even by blood. On microscopical examination 
the membranes contain epithelium, degenerated or not, and a homo- 
geneous intercellular substance, the basis of which is either mucin or 
other albuminoid substance. It is only in rare instances that the mem- 
branes have been observed in situ, and in these they were found in the 
colon, the mucous membrane of which presented no distinctive alter- 
ation. 

Symptoms. — Pseudo-membranous enteritis is characterized by attacks 
of colic followed by the evacuation of the typical discharge. The attacks 
of colic may last for several days, when relief is experienced, and inter- 
vals of months may elapse without a recurrence of the symptoms. There 
is no obvious exciting cause for the immediate attack, but with the 
repeated occurrence of the attacks depression of spirits, hysterical 
manifestations, and neurasthenic symptoms are frequent. The general 
nutrition and appearance of the patient may be but little affected. 
Pseudo-membranous colitis or mucous colic is usually an affection of 



DISEASES OF THE INTESTINE. 



871 



long duration, and treatment is generally of but little avail. Excep- 
tionally the disease has come to an end after one or a few attacks. 
Errors in diagnosis are likely to arise only from mistaking the remains 
of undigested food or vegetable or animal tissues for the characteristic 
membrane, but microscopical examination enables their nature to be 
quickly determined. 

Treatment. — For therapeutic purposes cases of pseudo-membranous 
disease of the intestine may be divided into— first, those in which there 
is habitual constipation ; second, those in which there is a tendency to 
relaxation of the bowels ; third, those in which constipation and diarrhoea 
alternate. The management of these varieties of the disease differs, but 
at the same time has much in common. 

In every case the hygienic management must be in accord with the 
general condition. Probably in the majority of bad cases there is a more 
or less pronounced neurasthenia, under which circumstances the rest-cure 
should be enforced with a rigor proportionate to the needs of the indi- 
vidual. Sometimes, even from the outset, graded increased exercise is 
required. Under all circumstances the abdominal bandage should be 
used day and night, and care should be taken to see that it is well fitting 
and continually in place. The bathing habits should be looked after, 
— the daily cool or tepid bath being employed as indicated. 

The diet should be carefully watched, and should be nearly the same as 
in chronic enteritis. The experience of the individual as to what does not 
agree with the digestion should be thoughtfully consulted. Sugar should 
be reduced to the minimum. Oatmeal should be denied, though corre- 
sponding wheat-foods are in some cases suitable. Potatoes, beets, and other 
vegetables which grow under the ground should be strictly forbidden ; 
whilst spinach, young peas, or Lima beans may be sparingly eaten. 
Macaroni cooked without cheese, rice, and milk foods are usually suit- 
able, and plain puddings and custards may sometimes be allowed. Hot 
bread and griddle- cakes are to be interdicted, and even stale bread must 
be used sparingly ; pulled bread and toast are preferable. Tea may be 
allowed, but coffee and chocolate are on the doubtful list. Alcohol in any 
form should be used with caution ; malt liquors are especially injurious. 

During the paroxysms of exacerbation the patient should be kept 
quiet, even confined to bed if not robust, should use free counter-irrita- 
tion along the whole length of the colon by means of iodine or sometimes 
«ven of flying blisters, and should take full doses of castor oil until its 
effects have become manifest, at the same time using large injections as 
spoken of in the following paragraph. Kelief cannot be expected until 
the membranous masses are thrown off. Between the exacerbations the 
treatment varies with the case. The tar mixture (formula 22) may be 
given continuously for weeks in every form of the disease. When there 
is distinct diarrhoea, carbolic acid and bismuth (formula 5) are very 
useful. No astringent should be employed more severe than the sul- 



872 



DISEASES OF THE DIGESTIVE APPARATUS. 



phuric acid mixture, with, occasionally guarana after meals. When there 
is constipation it is essential that the bowels be kept freely open day 
after day, and no hesitation should be felt in the use of laxatives. In 
many cases the senna mixture (formula 20) acts happily. If it does not 
suit, or if it has been taken for months and is losing its power, the daily 
use of the glycerin and castor oil mixture (formula 24) will in some 
cases be very effectual. These laxatives should, however, be varied : 
the sodium phosphate mixture (formula 19), cascara sagrada, the A.B.S. 
(aloes, belladonna, and strychnine) pill of the hospitals, and various com- 
binations of the vegetable cathartics, with eserine, may from time to time 
be used. Many individuals are greatly benefited by taking sweet oil 
after each meal, a dessertspoonful to two tablespoonfuls, with or without 
one to two teaspoonfuls of whiskey. Any derangement of digestion by 
the oil must be the signal for its withdrawal. 

Perhaps the most important part of the treatment in these cases is the 
habitual use of large enemata, which at first may be employed three or 
four times a week, afterwards once a week, or at irregular intervals, 
according to the necessities of the case. Two quarts of water, at 105° F. 
in the receptacle, variously medicated, should be given at a time. The 
remedies used in these enemata should vary as do local applications to 
mucous membranes in other portions of the body, and should have about 
the same range. Solutions of common salt or borax (varying from two 
per cent, to saturation, pro re nata) may do good. The most generally 
useful is silver nitrate (five to ten grains to the quart). Often it is better 
to give the silver injection at intervals of a week or more, with milder 
injections between. Judgment as to the effect of these injections is to be 
made by noting the character of the passages produced by them, the pain 
at the time of the injection, the tenderness along the colon after the in- 
jection, and the effects upon the passages for the next few days. In 
most cases it is essential to get rid of the mucus ; increase of the mucus, 
however, for several days after the injection, especially if it be associated 
with increased colonic tenderness, is evidence of irritation of the gut. 

ULCERATIVE ENTERITIS. 

Ulcers of the intestine arise usually in the mucous membrane, but 
sometimes develop in the serous coat, and are the result of a variety of 
causes. Many of them are of merely secondary importance, while others 
are the conspicuous characteristics of the disease in which they occur. 
The ulcers occurring in acute and chronic infectious diseases, as typhoid 
fever, dysentery, tuberculosis, and syphilis, in constitutional affections, 
as scurvy, gout, diabetes, malignant disease, and especially cancer, and 
those due to sharply defined causes, as strangulation of the bowel in 
acute intestinal obstruction, or localized disturbances of circulation, as 
ulcers of the duodenum, and those from thrombosis and embolism, are 
mentioned elsewhere. Those due to disturbances of innervation and 



DISEASES OF THE INTESTINE. 



873 



to amyloid degeneration are of such rare occurrence as to be of little 
clinical importance. 

As a result of catarrhal enteritis two varieties of ulcer occur. The 
one, called catarrhal, extends from the surface downward ; the other, the 
follicular, proceeds from an abscess of the lymph-follicle in the intestinal 
wall. The catarrhal ulcers are found especially in the large intestine, may 
be few or many, and when widely distributed tend to become confluent 
and give rise to extensive loss of substance. Islets of mucous membrane 
remain perhaps undermined or with polypoid projections. Extension in 
depth may lead to inflammation of the mesocolon, or even to perfora- 
tion of the bowel. Plealing of the catarrhal ulcer is possible, although 
unlikely to take place when they are numerous. 

The follicular ulcer usually occurs also in the large intestine, though 
sometimes present in the ileum. It represents one of the results of fol- 
licular enteritis, in which the inflamed lymph-follicles become abscesses 
and are discharged into the intestines : hence the ulcer from the outset 
is deep-seated. The wall is early undermined, and extensive destruction 
of the mucous membrane results, when the numerous follicular ulcers 
become confluent. The longer the process continues the less possible is 
it to distinguish by the anatomical appearances between catarrhal and 
follicular ulcers : indeed, many writers consider that they are essentially 
the same. 

Stercoral ulcers occur in various parts of the large intestine in conse- 
quence of long- continued retention of inspissated faeces, especially when 
containing lime salts and forming faecal concretions. This variety of 
ulcer is of especial importance in appendicitis. Formerly ulceration 
of the caecum was thought to be a frequent result of retained faeces, 
but it is now recognized that most ulcerations of the caecum of a non- 
tubercular or cancerous nature are due to a perforation from without of a 
peritoneal abscess caused by appendicitis. Multiple and small ulcers re- 
sulting from the irritation of retained faeces are sometimes observed at the 
flexures of the large intestine. They tend to girdle the intestine, and in 
healing may cause stricture. 

Amyloid ulcers have been described by a number of observers, although 
their occurrence is to be regarded as extremely rare. Indeed, considering 
the frequency of amyloid degeneration of the intestine and the infre- 
quency of this variety of ulcer, it would seem as if the loss of substance 
might be the result of conditions of which the amyloid degeneration is a 
complication. It is not unlikely that ulcers originally due to tuberculosis 
or syphilis, in which amyloid degeneration is frequent, may have been 
attributed to this affection of the intestine. 

Symptoms. — Ulcers of the intestine, whatever may be the cause, 
have but few characteristic symptoms ; indeed, extensive ulceration of 
the intestine may exist and there be no symptoms indicative of this 
lesion. As a rule, the more numerous and the larger the ulcers, the more 



874 



DISEASES OF THE DIGESTIVE APPARATUS. 



likely is diarrhoea to be present, and the course of the affection is that of 
a mild or a severe form of acute or chronic catarrhal enteritis. When 
the ulcers are limited to the large intestine the condition is regarded 
often as a catarrhal dysentery. Ulcers may occur in the large intestine 
with either no diarrhoea or with alternating constipation and diarrhoea. 
Pain is an inconstant symjitom, but when complained of it is colicky in 
character and produces persistent discomfort. If sharply localized and 
associated with constant tenderness in the region concerned, it is suggest- 
ive of the extension of the ulceration to the vicinity of the peritoneum. 
Ulcers are more especially indicated by the discovery of blood, pus, or 
shreds of tissue in the dejections, but the hemorrhage is often so slight as 
not to be detected even on microscopical examination. In like manner 
pus, though still more important as a characteristic of ulcer, may be so 
small in quantity as to be overlooked. Large quantities of pus in the 
intestinal evacuations are less suggestive of ulceration than of the per- 
foration of a neighboring abscess into the intestine. Shreds of tissue 
are absolutely characteristic, but are rarely found, except in the rapidly 
progressing ulcers of acute dysentery. 

The effect of intestinal ulcers upon the general nutrition is often slight, 
unless they are numerous in the small intestine or there is extensive 
destruction of the mucous membrane of the large intestine. More impor- 
tant in the progress of the ulcers is the occurrence of perforation, the 
immediate significance of which depends largely upon its seat. If it 
takes place along the line of attachment to the mesentery, a mesenteric 
abscess results ; if at the part of the bowel immediately covered by peri- 
toneum, general peritonitis is likely to follow. Embolism of the portal 
vein or stricture of the bowel at times follows ulceration. 

Treatment. — The treatment of ulcers in the small intestine is prac- 
tically that of chronic catarrhal enteritis. When the ulceration is in 
the large intestine the general management of the case is that of chronic 
enteritis ; but the main reliance must be upon local treatment. Intes- 
tinal antiseptics are chiefly of value as they remedy complicating con- 
ditions of the upper bowel. Bismuth and perhaps the tar preparations, 
when given by the mouth, may to some extent reach the large intestine. 

The most remarkable effects are at times to be obtained from a large 
injection, two quarts of water containing from one-half to one drachm 
of silver nitrate. Such injection may be repeated in three or four days, 
and perhaps a third or even a fourth time at intervals of a week. Between 
these injections the bowel may be washed out with a saturated solution of 
borax, not oftener than once in three days. It would appear probable 
that in obstinate cases various other local applications besides the silver 
nitrate might be advantageously applied to the intestine, notably weak 
solutions of zinc sulphate, or fluid extract of hydrastis, or mixtures con- 
taining bismuth subnitrate ; in our experience, however, no other local 
application has approached the silver salt in effectiveness. 



DISEASES OF THE INTESTINE. 



875 



DIPHTHERITIC ENTERITIS. 

This variety of inflammation of the intestine is characterized by super- 
ficial necrosis of the mucous membrane, the production of which is prob- 
ably intimately connected with the presence of bacteria and with faecal 
retention. The alterations are found at first in particular portions of 
the intestine, especially of the large intestine, and on limited parts of the 
surface, but rapidly extend in width and depth. 

A primary and a secondary diphtheritic enteritis are recognized. The 
former is the especial characteristic of diphtheritic dysentery j the latter 
is the result of various infectious diseases, especially of pyaemia and 
septicaemia of puerperal or of non-puerperal origin, cholera, typhoid 
fever, scarlet fever, and variola. It also occurs in certain chronic diseases, 
as tuberculosis, nephritis, cancer, and diabetes, and has been observed as 
a result of poisoning with corrosive sublimate. 

The anatomical appearances are sufficiently described in the article 
on dysentery, page 214, in which disease a diphtheritic colitis is fre- 
quent. 

The symptoms of a primary diphtheritic enteritis are those of dysen- 
tery. There may be no symptoms indicative of secondary diphtheritic 
enteritis, the lesions often being found unexpectedly at a post-mortem 
examination. On the other hand, especially in uraemic and mercurial 
cases, diarrhoea, colic, and even tenesmus,, may be present, but the stools 
are usually free from blood. The presence of a secondary diphtheritic 
enteritis may be inferred when symptoms of a severe colitis occur in 
connection with the above-mentioned causes. 

Treatment. — The treatment of diphtheritic enteritis is largely that 
of its cause, with the addition of such general and local measures as 
have been described under the head of acute and chronic enteritis 
and of dysentery. 

PHLEGMONOUS AND GANGRENOUS ENTERITIS. 

When the mucous membrane is infiltrated with pus, the condition 
is known as phlegmonous enteritis. It is of rare occurrence, and may be 
the result of a primary infection of the wall, as in malignant pustule. 
More often it occurs in consequence of ulcers, intestinal obstruction, 
strangulated hernia, or faecal impaction. The symptoms are those either 
of a severe enteritis or of a peritonitis. 

Gangrenous enteritis occurs when putrefaction of the necrotic mucous 
membrane occurs. It therefore represents a stage in the progress of 
ulcerative, diphtheritic, or phlegmonous inflammation of the intestine. 
It is oftenest present in dysentery, and is indicated by the discharge 
of discolored sloughs of an extremely offensive odor with considerable 
blood. Its further consideration is to be found in the article on dysen- 
tery, page 214. 



876 



DISEASES OF THE DIGESTIVE APPARATUS. 



Phlegmonous and gangrenous enteritis must be looked upon as second- 
ary or complicating disorders, for which there is no other treatment than 
that of the original cause, with the use of opiates or laxatives or astrin- 
gents and of various local remedies to meet symptoms as they arise. 

APPENDICITIS. 

The importance of recognizing the vermiform appendix as the usual 
source of the inflammations in the right iliac fossa, whether designated 
iliac abscess, iliac phlegmon, typhlitis, perityphlitis, paratyphlitis, or tuphlo- 
enteritis, led Fitz to offer the term appendicitis to indicate the primary 
disease whose results were so variously named. Despite the barbarism 
of the term, its practical importance has made it welcome. He showed 
by the comparison of a large number of cases of perforation of the ver- 
miform appendix with those receiving the clinical diagnosis of typhlitis 
or perityphlitis that the symptoms, course, and results of all had so 
many points in common as to indicate that inflammation of the vermi- 
form appendix was the essential feature; "that, for all practical pur- 
poses, typhlitis, perityphlitis, typhlitic tumor, and perityphlitic abscess 
meant inflammation of the vermiform appendix ; that the chief danger 
of this affection is perforation ; that perforation, in the great majority 
of cases, produces a circumscribed suppurative peritonitis tending to 
become generalized." 

Etiology. — According to Toft, the vermiform appendix was found 
diseased in one hundred and ten out of three hundred post-mortem 
examinations, and Hawkins found a like condition in sixteen out of 
one hundred autopsies. The causes of the great frequency of inflam- 
mation of the appendix which is indicated by these figures are due 
both to congenital peculiarities of structure and to conditions acquired 
after birth. Among the former are unusual length and abnormal 
position of the appendix, and irregularities in the development of 
its mesentery, which abnormities tend to favor the accumulation of 
material within the canal. The important causes acquired after birth 
are adhesions due to a localized peritonitis, either proceeding from 
the appendix or arising elsewhere in the abdomen, in consequence of 
which the appendix becomes adherent and is prevented from expel- 
ling its contents. Most important of all is the presence of faecal con- 
cretions or foreign bodies, the former being found in about one-half 
and the latter in at least one-quarter of the cases. Moulded, inspis- 
sated faeces, however, are often found in a normal appendix, and there- 
fore are to be regarded rather as a favoring than as the exciting cause 
of the inflammation. The same is true, though to a lesser degree, 
of the foreign bodies, which are various, and include seeds, bristles, 
worms, shot, beans, pills, and gall-stones. Digestive disturbances, or 
a strain or jar, such as may "take place in lifting, jumping, falling, 
or from a blow, are of etiological importance in at least one-third of 



DISEASES OF THE INTESTINE. 



877 



the cases. Usually, however, an attack begins without any obvious 
exciting cause. Appendicitis occurs oftener in males than in females, 
and especially in healthy youths and young adults, although it has been 
observed in an infant of twenty months and in a person seventy-eight 
years of age. 

Morbid Anatomy. — The varieties of inflammation which may be 
found in the appendix are the catarrhal, ulcerative, and gangrenous, each 
of which may be circumscribed or diffuse. The catarrhal and ulcerative 
forms of inflammation are acute or chronic, and end in resolution, per- 
foration, stenosis, or obliteration, while the gangrenous variety always 
ends in perforation. The appearances of catarrhal appendicitis are the 
same as those of catarrhal inflammation elsewhere in the intestine. But 
the tendency of all inflammation of the appendix is so strong to a rapid 
extension to the submucous, muscular, and peritoneal coats that the term 
infectious has been suggested by Morris to indicate the nature of acute 
appendicitis. When the appendix is removed within twenty-four hours 
after the onset of the symptoms, it is found often reddened and swollen 
throughout, with a cellular exudation in its wall. Ulceration of the 
mucous membrane of the appendix may be the result of a catarrhal 
inflammation and occur in the absence of a concretion or foreign body, 
even without symptoms, and is occasionally found in chronic appendi- 
citis. The base of the ulcer is formed by the submucous or muscular 
coat, and the surrounding mucous membrane is opaque gray and covered 
with mucus. The ulcer may heal, or, gradually extending in depth, 
eventually lead to perforation and the production of a circumscribed 
appendicular peritonitis. Stricture or partial or complete obliteration 
of the canal, with dilatation beyond the point of obliteration, may follow 
healing of the ulcer. Gangrenous appendicitis is of the greatest gravity, 
from the constancy with which it is associated with perforation, and in 
this variety a concretion or foreign body is often present. Gangrene and 
peritonitis, however, may result in the absence of foreign bodies or ulcer 
from the invasion of the wall of the appendix by bacteria present in the 
intestinal contents. The wall in contact with or in the vicinity of the 
concretion or foreign body is thin, of an opaque gray or greenish-yellow 
color, and often surrounded by a sharply defined line of demarcation. 
One or more openings, either pin-hole in size or large enough to admit 
the passage of a pea, are to be found when perforation exists, and the 
rest of the appendix may show but little alteration or may be reddened 
and swollen even to the size of the little finger. Frequently the entire 
appendix becomes detached, forming a slough. Chronic appendicitis is 
manifested by an enlargement of the appendix either from a thickening 
of its walls, especially of the mucous membrane, which is opaque gray 
and corrugated, or from hypertrophy of the muscular coat. The peri- 
toneum likewise is often thickened and opaque, either throughout or in 
patches. The altered appendix may lie free in the abdominal cavity, or 



878 



DISEASES OF THE DIGESTIVE APPARATUS. 



be adherent to the surrounding parts, or be embedded in dense fibrous 
tissue, often causing the thickened appendix to follow a tortuous course. 

A localized peritonitis is the usual result of the severer forms of ap- 
pendicitis, and is manifested at the outset by a dull, velvety surface of 
the appendicular peritoneum. Fibrinous exudation soon makes its ap- 
pearance as a gray or yellowish-gray membrane, which can be readily 
stripped from and sometimes forms a mould of the appendix. This fibrin- 
ous exudation causes adhesions between the appendix, the coils of intes- 
tine, and the abdominal wall. Soon a liquid exudation appears around 
the appendix and more or less rapidly increases in quantity. At first 
it is serous or fibrino- serous and is slightly opaque, but as it increases 
in quantity it becomes an opaque yellow pus, which, from its usual pres- 
ence in the immediate vicinity of the caecum, has been designated peri- 
typhlic abscess. This circumscribed appendicular peritonitis, how- 
ever, is to be found in the neighborhood of the appendix, and, according 
to the position of the latter, may be present in the region of the right 
kidney, the gall-bladder, the navel, the left iliac fossa, the hypogastrium, 
Douglas's fossa, or the inguinal canal. The peritoneal abscess may 
become large enough to contain several quarts of pus, and tends to break 
into the general peritoneal cavity, or into the intestine, especially the 
caecum. It may be discharged into the bladder or the vagina, or the 
pus may escape through the abdominal wall either near the navel or in 
the lumbar region, or from the inguinal canal, the thigh, or the hip. 
Faecal concretions or the sloughing appendix may pass through the open- 
ing and appear in an intestinal evacuation or in the discharge from the 
wound. In case of the communication of the abscess with a mucous 
canal and with the skin, the resulting fistula may remain open for months. 
The abscess sometimes extends to the space between the diaphragm and 
the liver, presenting the characteristics of a subphrenic abscess, perhaps 
to be followed by pleurisy or pericarditis. If the abscess lies in the 
vicinity of the internal iliac artery, the wall of this vessel may be per- 
forated and fatal hemorrhage result. 

Perforation of the appendix at times takes place before the general 
peritoneal cavity has been walled off by adhesions. In such cases a dif- 
fuse peritonitis results, the general peritoneum being injected and ecchy- 
mosed and a fibrinous or fibrino-serous exudation diffused throughout the 
abdominal cavity. Exceptionally an abscess resulting from perforation 
of the appendix lies in the subperitoneal tissue, forming a paratyphlitic 
abscess. This localization is likely to occur when the appendix is attached 
to the abdominal wall, either in consequence of developmental peculiari- 
ties or because of adhesions from a previous attack of appendicitis. If 
perforation takes place along the line of attachment, a retroperitoneal 
abscess arises which may extend in various directions and find outlets as 
various as those of the intra-peritoneal abscess. 

Among the occasional complications of appendicitis is abscess of the 



DISEASES OF THE INTESTINE. 



879 



liver. This is the result either of a pylephlebitis from the extension of 
a thrombophlebitis of the mesenteric vein leading from the appendix to 
the portal vein, or of embolism of the branches of the portal vein within 
the liver. 

Symptoms. — The recognition of symptoms of appendicitis is by no 
means so frequent as might be inferred from the observations of Toft and 
Hawkins of the prevalence of this disease. It is certain that many at- 
tacks of appendicitis are so latent as to produce either no symptoms or 
such slight disturbance as not to attract particular attention. The prac- 
titioner, however, is concerned with those instances in which positive 
symptoms are present : such cases may be conveniently grouped under 
acute and chronic appendicitis. 

Acute appendicitis is characterized by abdominal pain, tenderness in 
the right iliac fossa, elevation of temperature, circumscribed resistance, 
and digestive disturbance. Most important is the unexpected occurrence 
of the pain in a person previously well or suffering for a day or two from 
slight malaise, manifested by loss of appetite, nausea, constipation, or 
diarrhoea. Although the pain is generally unexpected, it may follow an 
obvious exciting cause, as an error in diet, a jar or strain, or the action 
of a purgative, and is sometimes associated with a chill or chilliness. It 
varies in character from a sense of discomfort to one of agony compel- 
ling the patient to make a sudden outcry. It is usually constant, though 
sometimes paroxysmal. At the outset it is often referred to the abdomen 
in general or to the hypogastric, umbilical, epigastric, or other region, 
but is soon localized in the right iliac fossa. The severe pain is probably 
due to the extension of the inflammation to the peritoneum, and we agree 
with Richardson in regarding it as evidence rather of an actual or threat- 
ening perforation of the appendix than of a simple catarrhal inflamma- 
tion. The surgeon often has found a perforation of the appendix at this 
early stage, when the pain resembled in character and severity that 
occurring in appendicitis recovering in the course of a few days under 
medical treatment. 

Of greater diagnostic importance than pain is localized tenderness, 
often exquisite, produced by either superficial or deep pressure. The 
seat of the tenderness is usually found in the right iliac fossa, within 
a radius of two inches from the anterior superior spine of the ilium. 
McBurney has observed it oftenest near the outer edge of the right rectus 
muscle, on a line between the navel and the anterior superior spine of 
the ilium (" McBurney 7 s point"). With the variation, however, in the 
position of the appendix the point of greatest tenderness may be found 
elsewhere in the right iliac fossa, or even in the umbilical or the lumbar 
region, in the left iliac fossa, in the groin, or in the pelvis. 

Elevation of temperature, however slight, is a most significant symp- 
tom of appendicitis, since it indicates the inflammatory origin of the 
pain and tenderness. Within twenty-four hours after the onset of the 



880 



DISEASES OF THE DIGESTIVE APPARATUS. 



pain the temperature may be less than 100° F., or it may rapidly rise 
above this point, especially in children, and throughout mild cases of 
appendicitis it may not exceed 101° F. In general, in a typical case of 
appendicitis an elevation of two or three degrees is to be expected, but 
a subnormal temperature may be present in the severest cases of acute 
appendicitis, in which general peritonitis is present from the outset. The 
pulse is quickened usually in proportion to the elevation of temperature, 
but is much accelerated in the grave cases even when the temperature 
is low. 

Eesistance on palpation of the wall of the right iliac fossa is next in 
importance to localized tenderness and elevation of temperature. During 
the first twenty-four hours after the incipient pain, especially when se- 
vere, the abdomen is often flattened, even retracted, and the tense right 
rectus abdominis muscle resists palpation, rendering it difficult, if not 
impossible, to distinguish a localized tumor if present. The abdomen, 
however, soon becomes distended and tympanitic, and though at first only 
moderately swollen it is afterwards considerably so. The circumscribed 
induration in the region of the appendix soon becomes apparent, and is 
usually found ' ' in the right iliac fossa below the line extending from the 
anterior superior spine of the ilium to the navel, nearer the former, and 
two finger-breadths above Poupart's ligament." The position of the 
induration varies, however, in accordance with the difference in the posi- 
tion of the appendix already mentioned. This induration is sometimes 
superficial, in close proximity to the anterior abdominal wall, but is more 
often deep-seated, and covered by the distended and usually tympanitic 
csecuni or by distended coils of ileum. The induration may be diffused 
or circumscribed, and, if originally diffused, tends eventually to become 
defined. It sometimes represents a resistant mass of the size and shape 
of the little finger, or is ovoid in outline. This circumscribed resistance 
is due to the swollen appendix and the surrounding peritoneal exudation, 
upon the abundance of which depends the size of the tumor. It is dull 
on percussion when near the surface, but at the outset is usually covered 
by resonant intestine, and later may be tympanitic from the mixture of 
gas with the exudation. Fluctuation becomes apparent only at a late stage 
in the disease, when the exudation so increases in quantity as to lie near 
the anterior abdominal wall. Pelvic examination in a case of suspected 
appendicitis in which there is doubtful resistance in the right iliac fossa 
should never be omitted, since a tumor as well as tenderness may thus 
be detected. 

The respiration is but little affected. There is loss of appetite, and 
vomiting is of frequent occurrence at the outset, but is usually temporary 
unless general peritonitis is present. Diarrhoea, though sometimes pre- 
ceding the attack, is generally absent, except at a late stage in protracted 
cases. Constipation is the rule. The examination of the blood usually 
indicates a leukocytosis, although Eichardson states that too much weight 



DISEASES OE THE INTESTINE. 



881 



should not be laid upon this sign. Increased frequency of micturition 
is sometimes an early symptom, but retention of urine, perhaps requiring 
the use of a catheter, not infrequently takes place for a while after the 
first twenty-four hours. The urine is high-colored and may be albuminous. 

In the further progress of acute appendicitis the tendency is towards 
resolution or perforation, with its resulting localized peritoneal abscess or 
general peritonitis. In these days of the frequent treatment of appen- 
dicitis, whether mild or severe, by laparotomy, it is impossible to obtain 
statistical evidence on a large scale of the relative frequency of these 
alternatives. According to the experience of most physicians in large 
practice, the termination in resolution is frequent. Of the one hundred 
and eighty cases designated typhlitis or perityphlitis analyzed by Fitz 
in his first communication, one- third ended in resolution. The statistics 
on this point of the greatest value are those given by Hawkins, who 
states that of two hundred and sixty-four cases of appendicitis admitted 
into St. Thomas's Hospital in consecutive order there was no suppura- 
tion in about seventy-two per cent., while there was a localized abscess 
pr a general peritonitis each in about fourteen per cent. Eichardson 
reports that of one hundred and thirty-seven cases of acute appendicitis 
seen by him thirty- six per cent, were mild cases and recovered without 
operation. In the personal experience of Fitz the course was mild in at 
least one-half of the cases. 

In the mild cases of appendicitis terminating in resolution the pain 
soon becomes localized, and is easily relieved by hot or cold applications 
or by small doses of morphine, although occasional twinges occur. The 
temperature is usually slightly higher at each evening observation than 
on the previous day until the third or fourth day, when it drops, often 
suddenly, sometimes gradually, to nearly the normal point. The abdo- 
men is only moderately distended, and there is usually but little nausea or 
vomiting. The localized induration in the region of the appendix shows 
no tendency to increase in size, and its sensitiveness rapidly diminishes. 
Although the action of the bowels is arrested and catheterization may be 
necessary to empty the bladder, the intestinal peristalsis and the function 
of the bladder are readily restored as the temperature falls. Spontaneous 
action of the bowels is often easily accelerated by the use of an enema. 

The severe as contrasted with the mild cases of appendicitis are those 
in which the pain requires repeated doses of an opiate for its relief, and 
in which the painful area increases at intervals of a few hours. There is 
but little fall in the morning temperature, and that of the evening is 
higher than on the previous day. Neither gas nor faeces escape from the 
rectum, and there is often retention of urine, although there may be a 
frequent desire to empty the bladder. The abdominal distention rapidly 
increases, and the region of tenderness spreads in all directions, frequently 
into the pelvis. 

In those severer cases which present the characteristics of a localized 

5G 



882 



DISEASES OF THE DIGESTIVE APPARATUS. 



peritonitis, two possibilities are especially to be anticipated : the one is 
the circumscribing of the inflammation to the vicinity of the appendix, 
resulting in the formation of a sharply defined, usually intra-peritoneal 
abscess, and the other is the generalizing of the peritonitis. 

The evidence of the formation of an abscess is furnished by the pres- 
ence of a tumor at the seat of the pain and tenderness in connection with 
the persistence of the elevation of temperature. The tumor is usually 
deep-seated, and sometimes to be felt with difficulty in consequence of the 
abdominal distention. The various positions it may occupy have already 
been stated, and the importance of a rectal examination in determining 
its pelvic seat is obvious. With the formation of the abscess temporary 
improvement often takes place, although the temperature remains still 
elevated. The general abdominal distention and localized pain may 
subside, and intestinal peristalsis be restored, and there may be so little 
constitutional disturbance that frequently patients with a large quantity 
of pus in the abdomen have walked into the hospital. 

Small abscesses may be absorbed, though slowly ; large abscesses tend 
to become discharged into the csecum, rectum, bladder, or vagina, or 
through the abdominal wall. A threatening evacuation into the rectum 
is often indicated by a frequent desire for defecation, and the escape 
of a gelatinous mucus, often blood-stained ; impending perforation into 
the bladder is at times indicated by frequent, scanty, and painful mic- 
turition. Sudden perforation of the wall of the abscess, with the escape 
of pus into the peritoneal cavity, is always to be dreaded. Even if the 
abscess diminishes in size by the gradual absorption of pus, the danger 
of the formation of an embolic abscess of the liver should always be rec- 
ognized. In this event chills, exacerbation of temperature, increased area 
of hepatic dulness, and pain in the region of the liver are likely to occur. 

Generalizing of the peritonitis sometimes takes place at the outset of 
the attack of appendicitis. The initial pain then is of extreme violence, 
and extends over the entire abdomen. There is often a severe chilL 
The temperature usually is subnormal, but the pulse is rapid and feeble. 
The abdomen is tense and retracted. The skin is cool, moist, and at 
times mottled with livid spots ; the eyes often are sunken, the face 
pinched, the voice husky. The patient may die during this stage of col- 
lapse, but not infrequently he rallies temporarily, the skin becomes hot, 
the abdomen distended, tympanitic, and fixed during respiration, and 
the pain and tenderness may diminish. Persistent vomiting is likely to 
occur, at times of a material resembling beef -juice, and death follows in 
the course of two or three days. These are the fulminating cases which 
offer so little hope from any form of treatment. More often the general- 
ization of the peritonitis takes place more gradually. Without any con- 
siderable change in the course of the temperature, as observed in the 
severe cases, the pain and tenderness rapidly and progressively spread 
from the starting-point, and require increasing doses of opiate for relief. 



DISEASES OF THE INTESTINE. 



883 



The pulse gradually increases in frequency, and its force weakens. There 
is inability to take nourishment, and vomiting is frequent and eventually 
fsecaloid. With progressive loss of strength the patient may be compara- 
tively comfortable, but rarely survives beyond the end of the first week, 
death not infrequently taking place suddenly and unexpectedly, often 
when the mental condition of the patient was so steadily improving as 
to make the outlook appear hopeful. 

Diagnosis. — A sudden attack of pain and tenderness in the right iliac 
fossa, associated with an elevation of temperature, however slight, in the 
great majority of cases is due to an attack of acute appendicitis. The evi- 
dence is strengthened if the symptoms are present in a young man. If the 
pain is intense, the tenderness exquisite, the abdomen retracted, and the 
right rectus muscle rigid, it is probable that perforation of the appendix 
is present or imminent, and the appearance of a circumscribed resistance 
at the usual seat of the appendix within twenty-four hours strengthens 
this probability. The attack of pain caused by disease of the appendix 
may be simulated by renal colic, whether due to the passage of concre- 
tions or to an acute hydronephrosis. Appendicitis is distinguished, 
however, from renal colic by the presence of fever, the gradual forma- 
tion of a tumor, and the absence of hematuria. Attacks of biliary colic 
due to the passage of gall-stones rarely simulate the pain from appendi- 
citis, but pain, tenderness, tumor, and fever due to acute inflammation 
and distention of the gall-bladder may closely resemble the symptoms of 
appendicitis. The pyriform shape, superficial seat, and mobility of the 
tumor, and the frequently associated jaundice, are absent in appendi- 
citis. An acute attack of pelvic peritonitis, especially of tubal or of 
ovarian origin, may be mistaken for an attack of appendicitis. The 
previous history of the patient and the results of pelvic examination may 
suffice for the exclusion of these sources of error in diagnosis. Acute 
intestinal obstruction, particularly when strangulation exists, or when 
caused by intussusception, may suggest the general peritonitis caused 
by perforation of the appendix. The tumor of intussusception is less 
tender, and the frequent tenesmus and bloody stools of this affection are 
lacking in appendicitis ; in internal strangulation from intestinal obstruc- 
tion the symptoms are not sufficiently characteristic to eliminate appen- 
dicitis. The severity of the symptoms is such, in case of doubt, as to 
demand surgical treatment. In rare instances typhoid fever has been 
regarded as acute appendicitis. The localized peritonitis from tubercu- 
lar mesenteric glands has proved a source of error in diagnosis, and in 
more frequent instances attacks of appendicular colic have been mis- 
taken for those of inflammation of the appendix. The simulation of 
appendicitis takes place late in typhoid lever, and the previous his- 
tory of the patient renders the diagnosis of appendicitis improbable. 
The progress of the disease or the presence of characteristic changes 
elsewhere may be necessary for the exclusion of the tuberculous con- 



884 



DISEASES OF THE DIGESTIVE APPARATUS. 



dition, and the absence of fever in appendicular colic suffices to exclude 
this symptom as evidence of inflammation of the appendix. 

Prognosis. — That appendicitis is frequently recovered from under 
medical treatment is a fact familiar to all physicians. The mild cases are 
usually not reported, and the mortality as given by the surgeon relates 
rather to the disease as affected by operation than to the disease alone. 

According to Porter, in a collection of four hundred and forty-eight 
cases the average mortality was about seventeen per cent., the death-rate 
in ninety-five cases treated medically being nearly fourteen per cent., 
while of three hundred and thirty-nine acute cases operated upon the 
mortality was about eighteen per cent. The figures of Hawkins are of 
greater value in determining the average mortality, since they represent 
experience at St. Thomas's Hospital under relatively uniform conditions. 
According to him, of two hundred and sixty-four cases the mortality was 
about fourteen per cent. All the cases ending in resolution, seventy-two 
per cent, of the whole, recovered, but of those ending in abscess twenty- 
six per cent, were fatal, and of those resulting in general peritonitis 
seventy-five per cent. died. Eichardson reports that of one hundred 
and thirty-seven cases of acute appendicitis seen by him thirty-six per 
cent, were mild cases and recovered without operation 5 of the cases 
operated upon, two-thirds recovered and one-third died. His experi- 
ence closely corresponds with the result of the analysis of one hundred 
and eighty cases designated typhlitis and perityphlitis made by Fitz in 
1886, — viz., recovery by resolution in thirty-two per cent. 

Although the average mortality of appendicitis may be stated as about 
fourteen per cent., the important question relates to the prognosis in 
the individual case. All mild cases recover under medical treatment, 
and the risks of surgical treatment lessen with the mildness of the symp- 
toms. The surgical operation attended with the least mortality is that 
done after the patient has recovered from an acute attack, — as is com- 
monly but erroneously stated, "in the interval between the attacks." 
While the symptoms are those of a mild appendicitis the individual 
prognosis is favorable, but they may suddenly or rapidly change, and 
the outlook in severe appendicitis is always uncertain. 

With symptoms of apparent equal severity in two patients, the one 
will die of general peritonitis while the other quickly recovers : 1 1 the 
progress of the disease needs to be watched with knife in hand." In 
mild cases of appendicitis the temperature usually falls by the third or 
fourth day, intestinal peristalsis is restored, pain and tenderness disap- 
pear, and recovery takes place in the course of a week or ten days. In 
the severe cases death from general peritonitis is especially to be feared. 
Of such cases sixty-eight per cent, died during the first eight days, one- 
third of these previous to the fourth day. The prognosis as to the indi- 
vidual depends, therefore, upon the presence or absence of the symptoms 
of an extension of the peritonitis, — nainely, rising pulse and temperature, 



DISEASES OF THE INTESTINE. 



885 



and increasing distention, with or without a tumor. The persistence of 
the temperature after the third or fourth day, and the presence of a sen- 
sitive tumor, even with a falling temperature, are indicative of a local- 
ized suppurative peritonitis, from which the pus may be absorbed, but 
following which liability to recurrent attacks is frequent. 

CHRONIC APPENDICITIS. 

In nearly one-half of the cases of acute appendicitis seen by Fitz 
there was more than one attack of the disease, separated by longer or 
shorter intervals of freedom from discomfort, and from his experience, 
therefore, the patient is as likely as not to have another attack. The re- 
current has all the characteristics and possibilities of the original affec- 
tion. The symptoms are the same, either mild or severe, and the prog- 
nosis does not materially differ, except that the more numerous the 
recurrences the less severe are they likely to be. If the intervals are 
long, perhaps months or years, each subsequent attack is regarded as a 
recurrent appendicitis. If the attacks are frequent, occurring at intervals 
of weeks or months, and in the mean time the patient is comparatively 
free from uncomfortable sensations in the region of the appendix, the 
condition represents a chronic appendicitis with a tendency to relapses, 
or simply a chronic or relapsing appendicitis. It is possible, however, for 
a chronic appendicitis to exist without relapses, although these usually 
occur, and the lesions characteristic of a chronic appendicitis may be 
present as the result of an acute attack, and there be no symptoms in- 
dicative of this condition. 

The disease chronic appendicitis, however, is to be recognized clini- 
cally by a series of symptoms localized in the region of the appendix. 
The essential feature in these symptoms is their persistence, intervals of 
relief being comparatively few. As Talamon has stated, chronic appen- 
dicitis is rather an infirmity than a malady menacing to life, and he has 
given the term appendicular colic to the frequent attacks of temporary 
pain in the region of the appendix. The patient is in a condition of 
more or less pronounced invalidism. Overwork or trivial disturbances 
of digestion produce pain and sensitiveness in the region of the ap- 
pendix, compelling the patient to remain quiet for a day or two. With 
the pain and tenderness there may be a slight elevation of temperature. 
Sometimes constipation is associated with or precedes the discomfort, and 
occasionally a dull, resistant mass of considerable size is to be felt in the 
region of the csecum, due to the retention of faecal matter. This combina- 
tion of retained fgeces and a painful and tender appendix is the stercoral 
typhlitis of the older writers, and is evidently the result of a mild attack 
of appendicitis associated with constipation. In such cases relief often 
follows evacuation of the bowels, perhaps from the removal of a me- 
chanical obstruction at the mouth of the appendix. On physical ex- 
amination of the right iliac fossa in the interval between the attacks of 



886 



DISEASES OF THE DIGESTIVE APPARATUS. 



pain, the enlarged appendix is often to be felt as a distinct tumor, per- 
haps of the size of the little finger, either directly beneath the abdomi- 
nal wall or deep-seated in the iliac fossa. At such times there may be 
even tenderness on palpation, and the patient is usually conscious of 
the localized resistance offered. The more frequent the recurrence of 
the symptoms and the shorter the interval between them, the more en- 
feebled the patient becomes. He is not infrequently prevented from 
continuous work ; he is debarred from the pleasures and profits of 
travel through fear of an attack of pain and its possibilities while at 
a distance from competent medical or surgical treatment. In addition 
to the constant uncertainty as to freedom from discomfort, there is always 
danger of the occurrence of an acute attack of inflammation resulting 
in perforation. He is often nervous and irritable, and becomes self- 
centred and timid. Pepper has characterized this condition as one of 
the most troublesome of curable affections. The symptoms may be pro- 
tracted over a period of years, and we are indebted to Treves for first 
advocating the removal of the appendix when the patient has recovered 
from an acute attack. 

Although the diagnosis of chronic appendicitis is usually easy, from 
the localization of the pain and tenderness and the frequent possibility 
of palpating the enlarged appendix, errors in diagnosis occasionally 
arise. In hypochondriasis and hysteria the patient often complains of 
pain in the right iliac fossa, and refers any disturbances of digestion or 
his general symptoms of nervous derangement to the diseased appendix. 
From such patients a normal appendix has been frequently removed. 
Critical observation shows that localized tenderness is often absent when 
the attention of the patient is diverted, and that there is no palpable 
tumor or localized resistance when the physical examination of the region 
of the appendix is made. In such cases oxaluria is not infrequent, and 
it is possible that irritation of the right ureter by the passage of crystals 
of calcic oxalate, as mentioned by Cabot, may explain the localizing of 
the discomfort. Patients with an inherited or acquired tendency to gout 
may have repeated attacks of renal colic from the passage of uric acid 
closely simulating relapses of discomfort in chronic appendicitis, and 
sometimes irritation in the course of the right ureter may occur in chronic 
appendicitis in consequence of the adherence of the appendix to the peri- 
toneum overlying the ureter. In such cases repeated examination of the 
urine becomes necessary, and the presence of crystals of uric acid or calcic 
oxalate or of blood- corpuscles is suggestive of the renal nature of the 
attack. Cases of chronic appendicitis sometimes closely simulate those 
of cancer of the caecum, for there is a condition of progressive loss of flesh 
and strength, failure of appetite, weakness of digestion, irregular action 
of the bowels, sometimes abundant mucous discharges, and a resistant 
tumor, not especially tender, in the region of the caecum. To eliminate 
this possible error in diagnosis, importance is to be attached to an accu- 



DISEASES OF THE INTESTINE. 



887 



rate history of the beginning of the attack and to the frequent observa- 
tions of the temperature. In such cases the diagnosis may first be made 
by means of an exploratory laparotomy. The prognosis of chronic ap- 
pendicitis, though in general favorable as to life, is always uncertain. 
The relapses or recurrences may gradually diminish in severity and the 
appendix become obliterated or destroyed perhaps during some severe 
recurrent attack. 

Treatment. — The treatment of the individual case of appendicitis 
is almost always surrounded with great anxiety, on account of the diffi- 
culty, in fact, in many cases the impossibility, of determining in the 
onset of a case whether it should be looked upon as one of fsecal accu- 
mulation in the caecum with associated inflammation of the appendix, 
or as one of mild catarrhal appendicitis, or whether ulceration or per- 
foration exists. 

The methods of treatment which have their advocates are not only 
various, but antagonistic, at least so far as the giving of drugs is con- 
cerned. All are in accord in inculcating absolute quiet in bed, with 
total abstinence at first from food other than chicken or other broths 
without rice or similar material in them, followed, when the time comes, 
by the addition of raw eggs or other albuminous liquid foods, pure milk 
being avoided on account of the tendency which it has to produce curds, 
although when diluted with carbonic acid water it is sometimes agreeable 
and useful. 

The points in regard to which there are great differences of opinion 
are : first, as to the use of local measures ; second, as to the use of opium ; 
third, as to the employment of calomel, and of saline or other purgatives ; 
fourth, as to operative procedures. 

Local applications consist in the use of heat and cold, of leeches, and 
of blisters. So far as concerns the use of heat or of cold, I believe that 
the sensations of the patient are the safest guide. If the continuous 
application of the hot-water bag gives the greatest comfort, it should be 
preferred. If the application of ice reduces the pain and is agreeable to 
the patient, it should be selected. Except in rare cases, the only objec- 
tion which can be urged against the proper use of leeches is the trivial 
influence the leech-bites may have on any surgical procedures that after- 
wards become necessary. I do not believe that this objection has much 
force ; it requires only a little more care thoroughly to disinfect the 
leech-bites than surgically to cleanse the sound skin. The effect of 
the leeches upon the disease varies with the character and the cause of 
the attack : if the attack is the outcome of ulceration or gangrene of 
the appendix, or if the appendix is the centre of an active infective 
process, leeches have no influence upon the local inflammation ; on the 
other hand, if the inflammatory action is the outcome of a typhlitis 
stercorals and is of slow development and of comparatively little force, 
leeches may be very useful, especially in gaining time for the employ- 



888 



DISEASES OF THE DIGESTIVE APPARATUS. 



nient of salines. Blisters I do not believe to be of any value in acute 
appendicitis. The blister increases the suffering of the patient and has 
little or no effect upon the spread of the inflammation ; it also interferes 
with the work of the surgeon. 

The question of opium is an exceedingly important one, concerning 
which there has been much discussion, which, so far as I am concerned, 
has led to some alteration of views. I still believe that opium does good 
in these cases by controlling pain and restlessness, and also acts antiphlo- 
gistically in some unknown way. On the other hand, there is great force 
in the surgical contention that opium interferes with intestinal secretion 
and peristalsis, and especially so masks the symptoms as greatly to en- 
hance the difficulties of deciding the progress of the case and the time 
at which surgical interference should be adopted. I believe, therefore, 
that unless opium is called for by the presence of excessive pain it is best 
to avoid it, and that when used it should be in the form of hypodermic 
injections of morphine. 

The difficulty surrounding the question as to the administration of 
salines is largely one of diagnosis. If the appendicitis is connected with 
faecal accumulation in the caecum, the administration of salines until the 
bowels have been thoroughly emptied is strongly indicated. If on the 
first day of a mild appendicitis there is the sense of the presence of a 
tumor imparted to the fingers on palpation, salines should always be 
given, and in many cases their use should be combined with that of 
calomel. It is better to give repeated small doses than a single large 
dose, — the large dose being much more apt to be vomited or to cause 
distress. Magnesium citrate is probably the best of the salines, on ac- 
count of the pleasantness of its taste, though sodium sulphate is prob- 
ably more certain in its action ; its bitterness, however, makes it more 
nauseating. 

It is a significant fact that whilst formerly scientific physicians utterly 
abandoned and condemned the use of calomel in such diseases as diph- 
theria, it was largely used by country practitioners, and through their 
influence has been forced back upon the leading members of the pro- 
fession. The same class of practitioners have so often affirmed to me 
that they have seen an appendicitis improve simultaneously with the 
coming on of ptyalism that I regard their evidence as of practical value. 
In the class of cases of appendicitis now under consideration, when there 
are no perforation and no gangrene or hopeless septic infection, in my 
opinion calomel should be administered. It acts as a laxative, and also, 
according to my belief, as an antiphlogistic remedy. 

At alternate half-hours the patient may take an ounce to an ounce 
and a half of magnesium citrate solution and a half-grain of calomel, 
the calomel being dropped when from seven to ten grains have been 
taken, even if no action of the bowels has occurred, and the saline being 
administered hourly, day and night, until a free passage has been obtained 



DISEASES OF THE INTESTINE. 



889 



or until the impossibility of so doing is demonstrated. When ulceration, 
perforation, or gangrene is present in an appendicitis the salines can do 
no good, and may readily do harm : so that they should not be exhibited. 
It is, however, impossible in most cases to determine positively when 
perforation or ulceration occurs, so that it may be considered as rule-of- 
thumb practice to use the saline in the beginning of an appendicitis 
which is not foudroyant or explosive in its type. If, however, the 
practitioner should believe that there is probably ulceration or gan- 
grene of the appendix, the purgative should be used only if absolutely 
necessary to overcome demonstrable faecal retention. The opinion of 
many of our best surgeons that the presence of faeces in the colon greatly 
increases the danger from the operation upon the appendix cannot be 
properly disregarded. In almost all cases of appendicitis high enemata 
are valuable : if there is reason to suspect that there is ulceration or 
perforation, they alone must be depended upon to clean out the colon ; 
if these complications are absent, they may be used to assist the saline 
laxatives. 

The most vital problem in any case of appendicitis is as to the pro- 
priety of surgical interference. Eesolution after ulceration and formation 
of an abscess is such a rarity that the possibility of its occurring in any 
case should not be taken into consideration. When, therefore, there is 
reason to believe during an acute appendicitis that perforation or the 
local formation of pus has occurred, or that the appendix has become gan- 
grenous, immediate operation should be performed. On the other hand, 
very frequently, perhaps in the great majority of cases, it is impossible to 
diagnose accurately the condition of the appendix : so that the question 
naturally presents itself as to what would be the result of operating 
upon every case as contrasted with the result of using the expectant 
treatment, with selection of cases for the surgeon. There are, however, 
no sufficient statistics to warrant definite conclusions on these points. 
The opinion put forth by some surgeons that the operation is free from 
danger is, in my opinion, erroneous. The question of the skill of the 
operator is in appendicitis a most important one : the operation should 
be undertaken with the greatest sense of responsibility, and only by 
those who by previous training are thoroughly prepared : it should be 
carried out with the most absolute asepsis. It being understood that a 
proper surgeon is available, the following rules seem the best that can 
be laid down for guidance in this matter. 

First, when in the onset of the attack the pain, the tenderness, and 
the tympany are excessive, and the fever and pulse rapidly rising, the 
probabilities of an acute perforating appendicitis are such that an imme- 
diate operation should be performed, each hour lost sensibly increasing 
the danger. 

Second, when in a case of mild appendicitis sixty hours of care- 
ful treatment have gone by without distinct abatement of the symp- 



890 



DISEASES OF THE DIGESTIVE APPARATUS. 



toms, the operation should usually be performed, except in the rare cases 
in which masses apparently fsecal in character have been detected at 
the beginning of the attack in the head of the colon and still remain 
there to some extent, especially if there has been tenderness along the 
course of the colon away from the immediate neighborhood of the ap- 
pendix. 

Third, an immediate operation should be performed when in a 
hitherto mild case a sudden increase in the local and general symptoms 
points towards the occurrence of perforation or the formation of pus, this 
rule being imperative if the acute symptoms are accompanied by such 
wide-spread general tenderness and marked increase in the fever and 
pulse-rate as to indicate the coming on of a general peritonitis. In such 
a case minutes are important, and unless the operation can be performed 
before the full development of septic peritonitis the result will almost 
certainly be death. 

During convalescence from appendicitis great caution should be ex- 
ercised in getting the patient back to ordinary food, and laxatives must 
be used freely if needed. Even after recovery care should be taken to 
avoid indigestible food, fruits containing seeds, violent exercise, or any 
exertion which will throw strain upon the abdominal muscles and 
which might, by breaking up an adhesion, stir up a slumbering inflam- 
mation. The bowels should be kept perfectly soluble ; if there be a 
remaining induration, persistent mild counter- irritation, especially with 
iodized oil, may be used locally. ~No drugs, except laxatives, are of any 
avail. 

Eecurrent appendicitis often finally gets well without operation, but 
certainly very grave risks attend leaving the case to nature. There 
are no reliable statistics which enable us to estimate accurately the mor- 
tality of operations between attacks of appendicitis, but Bull is probably 
not far from the truth in putting the rate at from five to six per cent. 
I believe this mortality to be far less than that which is the result of 
leaving the cases to nature, and that an operation should be performed 
if the past attacks have been very numerous, especially if they are in- 
creasing in frequency or severity, or if the attack last recovered from 
has been very alarming, or if the persistent severity of the local symp- 
toms between the attacks makes it probable that there is an abscess. 
Indeed, I am strongly inclined to go further, and to make it a rule to 
operate upon all cases directly after the recovery from a second attack, 
unless there is some very distinct reason for not doing so. The necessity 
for a person who has had two attacks of appendicitis always keeping 
within reach of a first-class surgeon is most pronounced, and sometimes 
is embarrassing. 

At the operation the appendix should be taken out, provided it can 
be done without too much injury or without such manipulations as may 
rupture possible adhesions or bring about the escape of septic matter 



DISEASES OF THE INTESTINE. 



891 



into the peritoneum. The question of removal or non- removal must 
be settled during the operation by the surgeon. — H. C. W. 



Eecognizing the impossibility of satisfactorily determining at the 
outset how an attack of appendicitis is to end, but convinced that the 
large majority of cases can recover quickly, easily, and safely under 
medical treatment, it seems to me advisable to advocate such treatment 
as shall favor the predominant tendency of this disease to terminate in 
resolution. 

From this point of view the essentials are to check peristalsis above 
the caecum and to relieve pain. Eepeated instances have occurred of the 
aggravation of the symptoms soon after the administration of laxatives 
by the mouth, often by an anxious mother who attributes the abdominal 
pain to the presence in the intestine of indigestible food or retained faeces. 
All cathartic medicines are, therefore, to be avoided until convalescence 
is established, and only the blandest liquid diet is to be permitted. If 
constipation has preceded the attack or the colon is distended with gas, 
a rectal enema often gives relief, and does not threaten the tearing apart 
of delicate adhesions whose influence is protective, or risk the perfora- 
tion of a weakened appendix. 

The relief of pain is best accomplished locally by means of hot or 
cold applications. If these are ineffectual, morphine should be given, be- 
neath the skin, by the mouth, or in suppository, in such quantity as to 
keep the patient comfortable. Small doses are usually sufficient for this 
purpose. 

If resolution is to occur, it is likely to take place by the third or fourth 
day : hence, when the condition of the patient permits, an operation 
should be delayed until this time. The surgical treatment of the acute 
attack is always to be avoided when possible, because it is unnecessary in 
the majority of cases, and is followed by the risk of a subsequent hernia. 
If eventually required, it is more safely employed in the absence of 
acute inflammatory symptoms, and there is afterwards less likelihood 
of hernia. 

The removal of the appendix for chronic inflammation is to be recom- 
mended in those cases in which recurrences are frequent or the tendency 
to relapses is such as to produce a state of semi-invalidism. — E. H. F. 

INTESTINAL OBSTRUCTION. 

Definition. — An internal mechanical interference with the action of 
the bowels, causing complete arrest of evacuation. 

In the usual restricted use of the term intestinal obstruction only 
the mechanical causes within the abdomen are considered. Acute is to 
be distinguished from chronic obstruction, although the causes of the 
latter may produce acute outbreaks. 



892 



DISEASES OF THE DIGESTIVE APPARATUS. 



Varieties. — The internal mechanical causes of acute intestinal ob- 
struction in two hundred and ninety-five cases were as follows : strangu- 
lation by bands and cords, by slits and fissures, and by peritoneal pouches, 
in thirty-four per cent., intussusception in thirty-two per cent., abnormal 
contents in fifteen per cent., twists and knots in fourteen per cent., and 
strictures and tumors in five per cent. Since cases of acute obstruction 
from abnormal contents and from strictures and tumors are of the least 
practical importance, and as obstruction from knots is extremely rare, it 
is convenient to remember that acute intestinal obstruction is due to 
strangulation or to intussusception, each, in about forty per cent., and to 
twists in about twenty per cent. 

Strangulation. — In seventy per cent, of the cases of strangulation by 
bands and cords a previous peritonitis was important in etiology, either 
by producing fibrous adhesions or by causing the adherence of the ap- 
pendages of the intestinal or genital tract. The intestinal appendages 
include the epiploic appendages, the vermiform appendix, persistent 
vitelline remains, the omentum, and the mesentery. The vitelline remains 
are Meckel's diverticulum (the vitelline duct) and the patent or oblit- 
erated vitelline blood-vessels. The diverticulum is usually connected 
by the blood-vessels with some part of the abdominal wall or contents, 
but may be adherent only in consequence of a localized peritonitis. The 
vitelline blood-vessels or their remains may likewise form a strangulating 
cord in the absence of the diverticulum, and are connected with the 
mesentery or the anterior abdominal wall, usually in the vicinity of the 
navel. Omental adhesions may result in the formation of a strangulating 
cord, or a loop of intestine may pass through a slit or fissure of the atro- 
phied or aplastic omentum. The rare strangulating slit of the mesentery 
and abnormal peritoneal pouches are attributable to defective develop- 
ment. Extremely rare is strangulation from rupture of the diaphragm. 
Seventy per cent, of the cases of strangulation occur in males, and forty 
per cent, in persons between the ages of fifteen and thirty. Strangulation 
in early youth is relatively uncommon, but when occurring it is usually 
due to vitelline remains. The small intestine is obstructed in nearly 
ninety per cent, of the cases, the lower abdomen is the seat of the 
strangulating object in eighty- three per cent., and the right iliac fossa 
in sixty-seven per cent. 

Intussusception. — In this variety of acute intestinal obstruction, 
according to the experiments of Nothnagel, a contracted portion of the 
intestine forces its way into the relaxed portion immediately below. The 
upper portion is thus invaginated into the lower, and more and more of 
the intestine may be forced into the sheath, which also often becomes 
simultaneously inverted, until the invaginated portion lies in the rectum. 
In seventy-five per cent, of the cases the ileum was invaginated into the 
caecum or into the colon, the ileo-ccecal and ileo-colic varieties. The small 
intestine was invaginated into itself, forming the enteric or ileal variety, 



DISEASES OF THE INTESTINE. 



893 



in twelve per cent, of the cases, while the invagination of the colon into 
itself or of the caecum into itself occurred in a like number of cases. 
Two-thirds of the cases of intussusception occurred in males, fifty-six per 
cent, in children under ten years of age, and thirty- four per cent, in 
infants less than twelve months old. Although diarrhoea or constipation 
is often present, and indigestible food, violent exertion, or injury imme- 
diately precedes intussusception in a certain number of cases, these factors 
are not of sufficient importance in etiology to require especial considera- 
tion. The immediate effect of the invagination is the production of a 
tumor, the appearances of which vary according to the duration of the 
intussusception. The tumor forms a sausage-like mass of intestine, and 
the inverted portion after death is often withdrawn with difficulty from 
the sheath, at the mouth of which the vermiform appendix, in the ileo- 
cecal variety, often protrudes. On opening the sheath the invaginated 
portion has a crescentic outline, in consequence of the traction of its 
mesentery. From the compression of the blood-vessels of the invaginated 
portion as it enters the sheath, the intestinal veins become distended 
with blood, the mucous membrane is of a purple color, and hemorrhages 
within or from the intestinal wall are frequent. The opposed peritoneal 
surfaces are covered with a fibrinous exudation forming adhesions, the 
presence of which is a means of distinguishing the intussusceptions oc- 
curring in the death-agony from those which are the cause of death. If 
the patient survives the immediate effects of the intussusception, necrosis 
of the invaginated portion takes place, and several feet of the intestine 
may be discharged as a slough. In such cases fusion of the mouth of the 
sheath with the intestine above the point of separation takes place, and 
eventually healing may result, usually ending in the formation of a fibrous 
stricture. 

Twists and Knots. — The large intestine is involved in eighty-seven 
per cent, of all cases of twist. About one-half of the twists of the 
large intestine are located at the sigmoid flexure, and one-third in the 
region of the caecum. The formation of the twist is promoted by the 
elongation of a loop of the intestine in consequence of hernia, the trac- 
tion of adhesions, or the prolonged accumulation of faeces. The affected 
part of the bowel is usually twisted along its axis for a half-turn, a 
whole turn, or even more, and a strangulation of the intestine is the 
result. The coil of intestine below the point of strangulation is dis- 
tended and purple, death in fatal cases usually resulting from general 
peritonitis. In rare cases a loop of the small intestine may be twisted 
about another portion. Nearly seventy per cent, of the cases of volvu- 
lus or twist are in males, and about one-third of them occur between 
the ages of thirty and forty years, although this cause of intestinal 
obstruction has been found at the age of six and beyond that of seventy 
years. 

Knots as a cause of intestinal obstruction are so rare as to be of no 



894 



DISEASES OF THE DIGESTIVE APPARATUS. 



practical importance. They are formed by the encircling of a coil of 
intestine by a neighboring loop, the free end of which so passes beneath 
the attached portion as to form a knot. The effect is to produce strangu- 
lation of the intestine. 

Strictures and Tumors. — Acute obstruction from strictures or tu- 
mors of the intestine or from abdominal tumors outside the intestine 
occasionally occur. The large intestine is usually obstructed, and the 
cause is generally seated in the lower half of the abdomen. These causes 
of obstruction are more often found in women, in consequence of the 
prevalence among them of abdominal tumors, and four-fifths of the cases 
occur after the age of forty. Cancerous tumors of the intestine cause 
acute obstruction more frequently than do fibrous strictures. Strictures 
of the intestine may exist at birth and be manifested by complete obliter- 
ation of the canal, as in imperforate rectum, or by the separation of the 
stomach from the duodenum. Acquired strictures result from the heal- 
ing of ulcers, especially of tubercular or syphilitic ulcers. A stricture 
may also result from the healing of the ulcer due to intussusception and 
of stercoral ulcers at the flexures of the colon. Although stricture of 
the intestine is of frequent occurrence in chronic dysentery, this variety 
is rarely sufficient to produce acute obstruction. 

Abnormal Contents. — Various foreign bodies introduced into the 
intestine by the mouth or by the rectum may become causes of acute in- 
testinal obstruction. These are taken in either accidentally, especially 
by children, or intentionally, as in the insane. Generally they are solid 
masses, as stones, coins, glass, nails, or false teeth. The common ab- 
normal contents which cause intestinal obstruction are biliary calculi, 
impacted faeces, and enteroliths. The enteroliths are composed in con- 
siderable part of undigested material, such as hair, thread, fruit-stones, 
or bits of bone. The deposition of calcium and magnesium phosphates 
takes place within or about these substances, and calculi are formed 
which may be as large as a hen's egg. Intestinal calculi may be com- 
posed of lime or magnesia taken as medicines for a long period of years, 
and cases have been reported of obstruction resulting from a mass of 
round worms. 

Gall-stones are found to be the cause of obstruction in three-fourths 
of the cases due to abnormal contents. The majority of the patients 
are women, all are adults, and six-sevenths of them are more than fifty 
years old. Obstruction from impacted faeces occurs with equal frequency 
in the two sexes and at all ages. 

Chronic obstruction is due to strictures, to tumors, or to foecal im- 
paction. The strictures are oftenest of a cancerous nature, though some- 
times due to tubercular, syphilitic, or stercoral ulcers, to the healing of 
an ulcer following the detachment of the slough in intussusception, or 
to a localized chronic peritonitis. The non - malignant tumors causing 
chronic obstruction are polypoid fibromata or lipomata. 



DISEASES OF THE INTESTINE. 



895 



Symptoms. — The principal symptoms of acute obstruction are pain, 
vomiting, tympany, and tumor. Stoppage of the bowels is an important 
symptom, though not always present throughout, and may be so com- 
plete that neither gas nor faeces escape. Frequent loose movements may 
be present at an early stage of intestinal obstruction, and are often a 
characteristic symptom of intussusception. When faecal retention is the 
cause of obstruction, numerous ineffective dejections are common. 

The pain is usually sudden and severe, and often colicky. In most 
cases it is referred to the abdomen in general, but occasionally it is lo- 
calized in one or another region of this cavity. In intussusception the 
initial pain may be of gradual onset, and is often manifested as tenesmus. 

At the outset tenderness is not an especial feature, and, indeed, it is 
not conspicuous throughout the attack. 

Vomiting occurs with great frequency. At first the food last taken is 
expelled, later a bile-stained fluid is ejected, and eventually a yellow fluid, 
the contents of the duodenum, appears, at first odorless, but becoming, on 
or about the third day, of an offensive odor, the so-called faecal or sterco- 
raceous vomiting. There is no satisfactory evidence, however, to warrant 
the idea that the contents of the large intestine are ever vomited, and in 
intussusception faecaloid vomiting is rare. Tympanitic distention of the 
abdomen, as a rule, soon makes its appearance. It may be enormous, 
but is usually moderate, and is less conspicuous in obstruction from in- 
tussusception than from strangulation. A palpable tumor is of great fre- 
quency in intussusception, but is only occasionally observed in the other 
varieties of acute obstruction. The tumor is composed of circumscribed 
distended intestinal coils, often with visible outline, and may be felt as a 
dense object in the case of abnormal contents. In acute obstruction from 
cancer the tumor is sometimes palpable, either by the rectum or through 
the abdominal wall, although acutely obstructing cancer is usually of the 
annular type, causing rather a stricture than a tumor. The presence of 
a tumor is most constant in intussusception, being apparent in nearly 
two-thirds of the cases. It is to be recognized on examination of the 
abdomen or of the rectum, more commonly of both, and is of early occur- 
rence, being found within the first three days in more than three-fourths 
of the cases. It is usually felt in the course of the large intestine, espe- 
cially in the region of the descending colon, as an elongated cylindrical 
mass, not freely movable, and often temporarily increasing in density 
during spasmodic and painful peristalsis. If the tumor is low down in 
the rectum there is often a relaxed sphincter, and the finger introduced 
into the rectum usually readily feels the slit-like opening of the lower 
end of the invaginated intestine. When the abdominal tumor is due to 
obstruction from faeces, it may occupy the entire abdomen or be limited 
to the course of the colon. It is elongated, rounded, nodular, slightly 
movable, hard, and dull on percussion. The faecal nature of the tumor 
is often to be determined by a rectal examination. 



896 



DISEASES OF THE DIGESTIVE APPARATUS. 



The temperature is frequently elevated, usually only to a moderate 
extent, especially after the first day of obstruction from strangulation, 
and may be subnormal, particularly when symptoms of collapse occur. 
On the contrary, if peritonitis supervenes the temperature continues to 
rise. The pulse at the outset is but little affected, but soon becomes 
quickened and feeble. Hiccough is only occasional, though the cause 
of much discomfort. The urine is usually high-colored and scanty, espe- 
cially when there is excessive vomiting, and may contain albumin and 
indican. 

Chronic obstruction is characterized by persistent constipation, 
extending over a period of months or years. Weeks may elapse with- 
out a movement of the bowels, or scanty dejections may pass through 
a tunnelled or channelled faecal mass in the colon. Very frequent in 
chronic obstruction by impacted faeces are repeated mucous discharges. 
Enormous faecal accumulations may exist and^very few symptoms arise, or 
pain, nausea, and vomiting may result. In rare cases chronic obstruction 
from impacted faeces may be followed by death from perforation of the 
intestine. Chronic intestinal obstruction from stricture or tumor is indi- 
cated not only by long-standing constipation, but also by abdominal pain 
or discomfort often referred to a definite point, which frequently proves 
to be the seat of the obstruction. There is progressive loss of flesh and 
strength, with not infrequently attacks of acute obstruction, which are 
relieved by appropriate treatment. As the patient becomes emaciated the 
outlines of the distended coils of intestine can be seen beneath the wall of 
the abdomen. There is visible peristalsis, associated with borborygmi. 
A rectal examination may enable the seat of the stricture or tumor to 
be determined, and palpation of the abdominal wall may indicate the 
presence of the tumor. In cases of irremediable chronic obstruction 
death results from progressive exhaustion, from a supervening acute ob- 
struction, or from peritonitis following perforation above the point of 
obstruction. 

Diagnosis. — The symptoms suggestive of acute intestinal obstruction 
— namely, pain, vomiting, tympany, or tumor, and arrested alvine dis- 
charges — may be due to external herniae : hence such sources of obstruc- 
tion should be excluded before internal causes are considered. The 
symptoms of acute intestinal obstruction so closely simulate those of 
peritonitis that a differential diagnosis between the two affections is often 
of extreme difficulty, and frequently is made first by means of an ex- 
ploratory laparotomy. At the outset the early presence of fever and 
general abdominal tenderness are suggestive rather of peritonitis than of 
intestinal obstruction. Persistent vomiting is more frequent in obstruc- 
tion than in peritonitis. The causes of peritonitis are to be eliminated 
as far as possible : hence evidence of antecedent disease should be sought 
in the gastro- intestinal, genital, and urinary tracts, in the biliary passages 
and the pancreas, in suppurating or necrotic lymph-glands, in embolism 



DISEASES OF THE INTESTINE. 



897 



of the mesenteric arteries, in latent appendicitis, and in suppurating 
inflammation in the vicinity of the peritoneum. 

The symptoms of acute intestinal obstruction are sometimes simulated 
by the results of a severe blow upon the abdomen, the after-effects of 
difficult and prolonged laparotomies, the reduction of a hernia, and at- 
tacks of biliary or renal colic. The history of the case, the localization 
of the pain, and the absence of jaundice and hematuria are usually suffi- 
cient to exclude these possible sources of error in diagnosis. Time often 
is necessary to determine whether the condition is one of acute internal 
mechanical obstruction or a localized or diffuse peritonitis. 

The part of the bowel obstructed is suggested by the history of the 
case, the appearance of the abdomen, and rectal examination. In ob- 
struction of the small intestine the abdominal distention is present at 
first in the epigastric and umbilical regions, and the tension is often tem- 
porarily reduced by vomiting. The urine is scanty and contains an 
excess of indican, and the symptoms of collapse usually occur within four 
days after the onset of the symptoms. In obstruction of the large intes- 
tine fsecaloid vomiting is generally absent or of late occurrence, the ab- 
domen is enlarged at first in the flanks and in the region of the trans- 
verse colon, and a palpable tumor is often to be recognized. Tenesmus 
and discharges of bloody mucus are frequent. 

Digital exploration of the rectum may disclose an intussusception, a 
tumor, a stricture, or hardened faeces when the large intestine is ob- 
structed. The determination of the capacity of the large intestine by 
injections of warm water is of value when examination by the finger is 
negative. A bulb syringe usually suffices for this purpose. The patient, 
anaesthetized if necessary, should be placed on the back, with the hips 
raised, or on the right side. A soft rubber tube should be introduced 
into the rectum for several inches, leakage through the anus being pre- 
vented by compresses around the inserted tube, which is connected with 
the syringe. The capacity of the large intestine of an adult is six quarts, 
that of the rectum three pints. The entrance of the larger quantity 
of water would indicate that obstruction was at or above the csecuin, 
whereas obstruction in the region of the sigmoid flexure would be sug- 
gested if only the smaller quantity of water could be introduced. The 
earlier the capacity of the large intestine is thus determined, the safer, 
since Thomas reports rupture of the intestine in a case of intussus- 
ception from an enema injected under light pressure on the third day. 
Exploration of the large intestine by means of a flexible tube is of 
but little value, since its entire length may be passed through the anus, 
and the tube be found, on digital examination, coiled within the rectum. 
The attempt to introduce a rigid tube may be dangerous, although rarely 
an unusually long rectum may permit the tip of the tube to be felt through 
the abdominal wall above the pelvis. 

In determining the cause of the obstruction it is to be remembered 

67 



898 



DISEASES OF THE DIGESTIVE APPARATUS. 



that practically sixty per cent, of all cases of acute internal mechanical 
obstruction are due to strangulation from bands, cords, twists, or knots, 
and forty per cent, to intussusception. The nature of the cause is to be 
inferred from a knowledge of the part of the bowel affected, the age of 
the patient, the special symptoms, and the relative frequency of the sev- 
eral causes of obstruction. Acute obstruction of the large intestine is 
due to intussusception or twists in eighty per cent, of the cases. If the 
patient is under thirty years of age, intussusception is more common than 
twist, and is indicated by tenesmus, tumor, and bloody stools. The ca- 
pacity of the colon as determined by injection is likely to be greater in 
intussusception than in twist, since the former is near the csecuni in 
seventy-five per cent, of the cases, while twist is at the sigmoid flexure 
in fifty per cent. If the patient is over thirty years of age and the evi- 
dence of intussusception is lacking, the obstruction is likely to be due to 
strangulation or a twist in which the symptoms are acute, or to a tumor 
or stricture, acute obstruction from which is preceded by symptoms of 
chronic obstruction, and the presence of which may be indicated by rectal 
examination. Strangulation affects that part of the large intestine near 
the sigmoid flexure, • while obstruction from cancer or stricture usually 
takes place below this region. Tumor and stricture are the commonest 
causes of acute obstruction of the large intestine, but, as already stated, 
are usually preceded by symptoms of chronic obstruction. 

Acute mechanical obstruction of the small intestine not due to gall- 
stones or foreign bodies is the result practically of strangulation. Gall- 
stones are to be eliminated by their usual occurrence after the age of 
fifty, the previous symptoms of cholelithiasis in one-half the cases, the 
late occurrence of tympany, and the occasional recognition by palpation 
of a hard, movable nodule in the abdomen. The history of the case when 
the resistance is palpable may indicate the presence of a foreign body. 
Strangulation is due to adhesions in seven-tenths of the cases and to 
vitelline remains in one-fifth. It is of importance to remember that the 
causes of strangulation of the small intestine are to be found in the lower 
abdomen in four-fifths of the cases. 

The diagnosis of chronic obstruction is readily made from the per- 
sistent constipation. The presence of impacted faeces may be recognized 
on physical examination of the abdomen and rectum, and freedom from 
discomfort and constipation after their removal makes the diagnosis clear. 
If relief is not experienced, the presence of a stricture or tumor is ob- 
vious, especially when distended intestinal coils are visible. Abdom- 
inal palpation may reveal the presence of a tumor, or rectal exploration 
may disclose or make probable a stricture or a tumor, the nature of which 
is usually to be determined only by an exploratory laparotomy. 

Prognosis. — Acute intestinal obstruction is a grave affection, but the 
prognosis varies especially in accordance with the cause. Obstruction 
from strangulation is almost uniformly fatal unless timely surgical treat- 



DISEASES OF THE INTESTINE. 



899 



ment has afforded relief. Symptoms of collapse early arise, and death 
usually results between the second and the fourth day. Possible excep- 
tions to the rule are to be admitted, for in rare instances relief from the 
symptoms has followed medical treatment. A spontaneous reduction of 
the strangulated intestine and the reversing of the twist are conceivable, 
though not sufficiently probable to be offered in evidence against surgical 
treatment. In obstruction from intussusception death occurs with the 
greatest frequency between the third and the fifth day, although sponta- 
neous recovery sometimes takes place by a reduction of the intussuscepted 
intestine or by its discharge as a slough. The mortality is least severe 
in case of the rectal variety. Of thirty -five cases of other varieties of 
intussusception treated medically, seventy per cent, died and thirty per 
cent, recovered. The surgical treatment of this affection in thirty-six 
cases showed a mortality of eighty per cent. In obstruction from gall- 
stones two-thirds of the cases medically treated recovered. Of the cases 
treated surgically, one-fifth recovered. Obstruction from faeces sometimes 
proves the cause of death by perforation of the bowels or from the pro- 
gressive enfeeblement of a person already debilitated by age or disease. 
In obstruction from strictures and tumors, although recovery from the 
immediate symptoms may take place under medical treatment, a radi- 
cal cure is to be obtained only by surgical measures. The frequent 
malignant nature of the stricture or tumor usually makes such treatment 
merely palliative, even if the patient recovers from the effects of the 
operation. 

Treatment. — In acute intussusception all food should be withdrawn 
for the time being, and the bowels should be kept completely at rest by 
full doses of opium, which should usually be given in suppositories. As 
the formation of adhesions practically puts an end to the possibility of 
withdrawing the intussuscepted intestine, immediate efforts should be 
made to get the gut into its normal position. The best method of doing 
this is to put the etherized patient in an inverted position, and adminis- 
ter, by means of a fountain-syringe, elevated from six feet for an infant 
to fifteen feet for an adult, warm saline solutions of olive oil, the nozzle 
of the syringe being inserted up to the sigmoid flexure ; whilst full of 
fluid, under pressure, the bowel should be systematically compressed and 
kneaded from below upward, great care being exercised not to use undue 
force, whilst from time to time the patient is well shaken. If no success 
attends this procedure, dilatation of the intestines, by forcing into them 
from a large india-rubber bag two to four gallons of atmospheric air, or, as 
preferred by Senn, hydrogen gas, may be tried. The practice of injecting 
into the intestines a solution of sodium bicarbonate followed by one of tar- 
taric acid seems to us somewhat risky, on account of the difficulty of 
controlling the amount of gas evolved. After the first twenty-four hours 
of intussusception, hydrostatic and pneumatic treatments are alike dan- 
gerous ; the case should be at once operated upon, or be left to nature, 



900 



DISEASES OF THE DIGESTIVE APPARATUS. 



aided by careful feeding with small quantities of strong broths, warm 
local applications, and the persistent use of opium to mild narcotism. 
If during the treatment the stomach becomes very much distended, it 
may be washed out, often with advantage. 

In the cases collected by Fitz the mortality without laparotomy was 
sixty-nine per cent., with operation eighty-three per cent. In Ashhurst's 
statistics the mortality- rate with operation was about seventy per cent., 
practically the same as that of a large number of cases not operated upon 
collected by Leichtenstern. Improving technique will probably lessen 
somewhat the surgical mortality, but at present the exact value of lapa- 
rotomy in intussusception, especially if the patient is an infant, has not 
been determined. The operation, if performed at all, should not be 
postponed longer than twenty-four hours. Enterotomy may be prac- 
tised as a late operation when the abdominal distention and distress are 
very great. 

In cases of chronic obstruction of the bowels, if relief is not afforded 
by careful regulation of the diet, treatment of catarrh or other causative 
or complicating disorder, and the use of very mild laxatives and enemata, 
with opium and belladonna as required, laparotomy should be performed, 
followed, if the obstruction be found irremovable, by enterectomy, if the 
patient be strong enough, or by the formation of a false anus. 

CANCER OF THE INTESTINE. 

Although cancer of the intestine is the most frequent mechanical cause 
of chronic intestinal obstruction, it often occurs without producing this 
result, and therefore it requires separate consideration. 

Etiology. — Intestinal cancer is more common in men than in women, 
especially after the age of fifty. The importance of local causes, par- 
ticularly the mechanical action of fseces, is suggested by the almost 
invariable presence of the disease in the large intestine, its occurrence 
in the rectum, according to Leube, in four-fifths of the cases, and its limi- 
tation to the csecum, or to the sigmoid, splenic, and hepatic flexures, in 
the remaining fifth. 

Morbid Anatomy. — For practical purposes all malignant tumors 
of the intestine are included in the description of cancer, since it is the 
latter that is oftenest present, and its symptoms do not differ from those 
produced by sarcoma or lymphoma. From the easily recognized physi- 
cal characteristics, soft, hard, and gelatinous cancers are differentiated. 
The distinction between malignant adenoma and cancer is one of but little 
value, since the epithelioid cells of cancer are often cylindrical, as are 
those of adenoma and malignant adenoma. Malignant adenoma presents 
the clinical characteristics of cancer, and the distinction between adenoma 
and malignant adenoma is to be determined only by the lapse of time. 
The gross appearances of cancer of the intestine do not differ essentially 
from those of cancer of the stomach or of the oesophagus. It arises in the 



DISEASES OF THE INTESTINE. 



901 



deeper portion of the mucous membrane, and as it increases in size ex- 
tends laterally and in depth and projects in the form of a nodule. This 
continues to enlarge, and may exist above the surface of the intestine 
as a flattened induration with sharply defined, perhaps everted, edges, 
either isolated or associated with smaller nodules. The cancerous growth 
may also encircle the intestinal tube and form a broad or narrow ring. 
The overlying mucous membrane becomes destroyed, and superficial por- 
tions of the cancer die, and are rubbed off or torn away, an ulcerated 
surface remaining. As the disease extends to the submucous and mus- 
cular tissues it invades the neighboring tissues or organs, the ulcer be- 
comes deepened, and perforation of the intestine may result, with the 
establishment of communication between adjacent coils of intestine or 
with the bladder or the vagina. Multiple nodules are likely to appear 
in the peritoneum, and to be found in the liver, in the lungs, and even 
in the more remote portions of the body. 

Symptoms. — Cancer of the intestine, as a rule, causes no suggestive 
symptoms referable directly to the intestine until ulceration, stricture, or 
tumor is apparent, and the disease exists, therefore, often for a long time 
before its presence is suspected. Irregular action of the bowels may be 
present for years without other disturbance until localized pain, slight 
tenderness, and perhaps ill- defined induration, occur. The pain at the 
outset is manifested as a sense of constant though slight discomfort, but 
in the course of time becomes colicky in character, its severity increasing, 
and when in the rectum has the characteristics of tenesmus. In rectal 
cancer a dull ache may be referred to the sacral or coccygeal region, and 
the desire for defecation is frequent and irresistible, evacuations of the 
bowel being followed by temporary relief. Of especial importance in 
exciting suspicion of cancer in connection with the above symptoms is 
loss of flesh and strength out of proportion to the discomfort from which 
the patient suffers. Cachexia results despite the good appetite, the normal 
digestion, and the freedom from change in the quality and quantity of the 
excrement. The faeces are sometimes ribbon-like or furrowed when the 
lower part of the intestinal canal is narrowed by a cancerous stricture. 
The serious nature of the symptoms is often first suggested by the presence 
of blood or of blood-stained mucus in the dejections, and the suspicion of 
an ulceration becomes strengthened by the presence in the intestinal dis- 
charges of pus or shreds of tissue, the cancerous nature of which is some- 
times to be recognized on microscopical examination. With the occur- 
rence of ulceration pain and diarrhoea become constant and severe, the 
appetite fails, digestion weakens, and there is rapidly increasing pallor 
of the skin. 

The symptoms indicative of the progress of cancer of the intestine 
towards the formation of a stricture have already been mentioned in the 
article on intestinal obstruction. It may be repeated, however, that an 
attack of acute intestinal obstruction may first excite the suspicion of a 



902 



DISEASES OF THE DIGESTIVE APPARATUS. 



cancer, and that repeated attacks of acute obstruction with intervals of 
comparative comfort are oftenest due to cancer of the intestine. As a 
rule, however, constricting cancer of the intestine produces symptoms 
rather of chronic than of acute obstruction. 

The formation of a visible or palpable tumor in cancer of the intestine 
belongs usually to the late stage of its progress, and is more likely to take 
place when the cancer affects either the csecuni or the rectum. The 
tumor is largely due to the extension of the disease to the tissues outside 
the intestine. It may be composed in part of coils of intestine united by 
cancerous adhesion and in part of retained intestinal contents. Varia- 
tions in the shape and consistency of the tumor thus arise, and not infre- 
quently rapid modifications in size result from diminution or increase in 
the mass of the accumulated intestinal contents. The tumor may be 
small, dense, nodular, floating or fixed, superficial or deep-seated. It 
may be large, rounded, and smooth, causing a projection of the abdomi- 
nal wall, especially conspicuous in an emaciated person. There may be 
but little change in the apparent size of the tumor for weeks or months, 
or the mass may attain the size of an infant's head in the course of a few 
weeks, the growth being so rapid and the consistency so soft as to suggest 
the presence of fluid. 

If stricture is present, the abdomen is enlarged, and distended coils of 
intestine are often easily recognized. If the cancer progresses without a 
tendency to stricture, there may be nothing abnormal in the appearance 
of the abdomen, or it may be even flattened. 

On rectal examination the cancerous growth is often found within 
reach, and secondary tumors in Douglas' s fossa are frequently felt when 
palpation of the abdomen fails to reveal the primary cancer. 

When the significant conditions of ulceration, stricture, and tumor 
become apparent the course of cancer of the intestine is usually rapidly 
progressive, and a fatal termination may be expected within six months 
or a year. A speedily fatal issue follows perforation, which sometimes 
takes place ; usually death results from progressive loss of flesh and 
strength, with eventual oedema of the lungs. Frequent complications 
are hydronephrosis and fibrous nephritis, due to stenosis of one or both 
ureters from the extension of the cancerous infiltration to their wall. A 
fatal termination is often hastened by the production of a cancerous peri- 
tonitis, or by the occurrence of a septic infection in consequence of the 
formation of a recto-vesical fistula. Death sometimes occurs suddenly 
and unexpectedly from embolism of the pulmonary artery secondary to a 
thrombosis, which occasionally occurs in the iliac vein. 

Diagnosis. — The cancerous nature of the ulcer or stricture of the in- 
testine which is invisible or beyond the reach of the finger is usually to 
be diagnosticated only by means of an exploratory operation, and the 
cancerous nature of a tumor of the intestine is often to be arrived at only 
by exclusion, unless the removal of a fragment of the larger and softer 



DISEASES OF THE INTESTINE. 



903 



growths by means of an aspirator has led to the positive diagnosis of its 
nature. Faecal tumors are eliminated by appropriate treatment. An 
occasional source of error is chronic appendicitis, which may produce 
an induration in the vicinity of the caecum and be combined with faecal 
retention and slimy dejections. In doubtful cases exploratory lapa- 
rotomy is to be recommended, since a cure is to be expected if the 
disease is of inflammatory origin, and the prognosis is not changed if 
cancer is present. Most important in the exclusion of other abdominal 
tumors which might simulate cancer of the intestine is inflation of the 
bowel, which serves to show the relation of the tumor to the course of the 
large intestine, its usual seat. 

Prognosis. — The prognosis of cancer of the intestine when treated 
medically is invariably fatal. When treated surgically the result varies 
largely in accordance with the seat of the tumor and the time of its dis- 
covery. If low down in the rectum, where it is often early recognized, 
permanent or prolonged freedom from the disease has repeatedly been 
observed after operation. The prognosis of cancer in other portions of 
the intestinal tract is to be considered as fatal, since the symptoms of its 
presence usually become manifest at a time when the disease has extended 
to other parts and complete removal is impossible. 

Treatment. — Medical treatment of cancer of the intestine consists 
solely in the relief of pain by opiates and the combating of obstruction 
by suitable diet, laxatives, and enemata, and, in case of eventual need, 
by punctures of the intestine with a hollow needle. J. G. Blake suc- 
ceeded in keeping a patient alive for eighteen weeks during which there 
was complete obstruction. During this time the intestine was punctured 
one hundred and fifty times, some eight ounces of liquid faeces being 
removed each time. 

CONSTIPATION. OBSTIPATION. COSTIVENESS. 

Definition. — Sluggish action of the bowels. 

Etiology. — The intestinal contents are forced onward as the result of 
peristalsis ; from twelve to twenty hours are necessary for their passage 
from the caecum to the anus, although but four hours are required for 
their journey from the pylorus to the caecum. The arrest of the peri- 
stalsis by mechanical obstruction is considered in the article on intestinal 
obstruction. When peristalsis is checked by atony of the muscular coat 
from congenital weakness or acquired degeneration, by deficient nervous 
excitability, or by peculiarities of the contents, persistent constipation is 
the result. Congenital weakness may be the cause of the enormous en- 
largement of the colon which is at times seen in young children, and 
which persists despite the induction of free evacuations by means of 
appropriate treatment. Acquired degeneration of the muscle is of fre- 
quent occurrence in chronic catarrhal enteritis, in chronic peritonitis, and 
in amyloid disease of the intestine. Deficient nervous excitability may 



904 



DISEASES OF THE DIGESTIVE APPARATUS. 



be due to organic disease of the brain or spinal cord, or to functional 
derangement, as in neurasthenia, hysteria, and certain forms of insanity, 
or to local affections of the intestine, as chronic passive congestion or in- 
testinal catarrh. The excitability of the nervous apparatus of the intes- 
tine varies in individuals, and is weakened by sedentary habits and negli- 
gence. The intestinal contents become abnormal and cease to produce 
the necessary excitation both from an excess and from a diminution of 
vegetable constituents. A deficiency of liquid, whether due to a dry 
diet or to profuse sweating, as in excessive muscular work or fever, is of 
marked importance in the causation of constipation ; but an abundance 
of milk in some persons produces this result. Muscular spasm in the 
lower part of the rectum, oftenest excited by a painful fissure of the anus 
and sometimes by ulceration of the mucous membrane, irritable prostate, 
a retrofiexed uterus, or a displaced ovary, at times proves a cause of 
obstruction. Many writers assign importance to weakness of the abdomi- 
nal muscles resulting from repeated pregnancies or due to the excessive 
accumulation of fat. 

Symptoms. — The effects of habitual constipation vary extremely, but 
are most exaggerated in persons of a nervous temperament, who com- 
plain of headache, dizziness, mental sluggishness, depression of spirits, 
and wakefulness, with loss of appetite and a coated tongue. The nervous 
symptoms are frequently attributed to the absorption of the toxic prod- 
ucts of decomposition in the intestine. Faeces and putrefactive bac- 
teria, however, are the normal contents of the large intestine, in which 
the faecal retention takes place, and there is no exact evidence that any 
undue absorption of putrefactive products occurs. 

The tendency of prolonged constipation is to the accumulation of 
faeces, resulting in faecal impaction. Increasing distention of the abdo- 
men then takes place, and distended coils of intestine are at times to 
be seen, especially in a thin person. The accumulated faeces are found 
especially in the rectum, sigmoid flexure, descending colon, and caecum, 
more rarely at the splenic and hepatic flexures, and may be present 
simultaneously in various parts of the large intestine. Palpable tumors 
but little sensitive to the touch result, and are to be felt through the ab- 
dominal wall, and the nature of the mass when in the rectum is readily 
determined on digital examination. The local effects of the faecal tumors 
vary considerably. The impaction of faeces in the rectum usually gives 
rise to frequent distress from the constant desire for evacuation, although 
only a small quantity of slimy matter escapes. In consequence of the 
pressure of the mass upon the wall of the rectum there is passive conges- 
tion, indicated by piles and leucorrhoea, or pain when the pelvic plexus 
of nerves is compressed. Impacted faeces elsewhere in the large intestine 
may prove discomforting from their weight and mobility, and may be 
mistaken for an abdominal neoplasm. Ulceration of the mucous mem- 
brane in contact with the faecal mass may occur, and attention has been 



DISEASES OF THE INTESTINE. 



905 



called to the possibility of the production of strictures in the healing of 
such ulcers. Ulceration of the caecum rarely results from the presence 
of faeces in this part of the bowel, but painful tumors in the right iliac 
fossa may be due to the association of appendicitis with faeces in the 
caecum. Eetention of scybala in diverticula of the colon may be fol- 
lowed by an inflammation of the wall, extending to the peritoneum or 
into the mesocolon. Faecal retention in the sigmoid flexure is an impor- 
tant element in the production of twist of this part, partly by elongation 
of the loop resulting from the long- continued traction, and partly because 
the weight of the loop facilitates its turning. The occurrence of attacks 
of acute intestinal obstruction from impacted faeces has already been 
mentioned. 

Diagnosis. — The diagnosis of chronic constipation is usually readily 
made from the history of the case and from the effect of treatment. It 
is to be remembered, however, that, although one daily evacuation of 
the bowels is the custom of most healthy adults, exceptional persons are 
found in whom one movement every three or four days is considered 
to be normal. It is also important to bear in mind that frequent move- 
ments of the bowels and abundant slimy discharges may be associated 
with and result from chronic constipation. The discharges may appear 
normal when the impacted faecal mass is tunnelled or channelled, but are 
usually hard, dry, and lumpy, sometimes resembling sheep-dung. 

Treatment. — In the treatment of chronic constipation it is a matter 
of the first importance to remove the cause. In a large proportion of 
cases constipation in part or altogether depends upon sedentary habits, 
so that systematic graded exercise must be insisted upon, in the open air 
if possible, in the gymnasium or training-quarters if necessary. Along 
with the general exercise, which should be carried far enough to get the 
person into good muscular condition, should be associated movements 
which are especially adapted to strengthen the abdominal muscles and 
increase the activity of the abdominal circulation ; many of the so-called 
" Swedish" movements are valuable for this purpose. They should be 
taught to the patient and rigorously carried out daily. In some cases 
good is achieved by the patient lying on his back and rolling around and 
around on the abdomen daily for ten to twenty minutes a large ball of 
heavy wood or iron. The habit of defecation at a certain time must also 
be formed ; for most persons the morning hour is the most convenient ; 
the time of day, however, is a matter of no importance from the purely 
medical stand-point, though the daily regularity is essential. 

Constipation is very often associated with hypochondriasis, so that 
care must be exercised not to enhance the importance of the symptom in 
the sensitive consciousness of the patient. 

If, as is frequently the case, the subject habitually uses fluids in small 
amount, the habit of free water- drinking should be formed, in the hope 
that the intestinal as well as the other secretions will be rendered more 



906 



DISEASES OF THE DIGESTIVE APPARATUS. 



abundant. At least in the United States, it is well to caution the patient 
against the taking of very large quantities of ice-cold drinks, which are 
especially deleterious when there is chronic gastric catarrh or atony of 
the digestive organs. From eight to sixteen ounces of water drunk at 
bedtime, or upon rising in the morning, or, better, at each time, are often 
distinctly effective in promoting morning defecation. 

The character of the food taken must be adapted to the individual 
case. The law is that the greater amount of the residue incapable of di- 
gestion in the food the greater its laxative influence ; witness the contrast- 
ing habitual conditions of the dog and the cow : hence laxative articles 
of food are — fresh or dried fruits, all green vegetables, and various grains 
ground entire, that is, without separation of the hull from the starchy in- 
terior. Sugars and substances containing them are laxative, although 
they are altogether digested. Among the individual articles of food, 
cracked oats and rolled oats stand pre-eminent ; they are, however, prob- 
ably not superior to rolled wheat as a laxative, and are distinctly less di- 
gestible. Graham and other forms of bread made of unbolted flour are 
much superior to white bread. Eice is scarcely laxative. Oils, especially 
vegetable oils, such as that of the olive, are mostly laxatives, and when 
they can be digested are very valuable additions to the diet. Especially 
is this the case when along with the constipation there is a tendency to 
failure of the general nutrition. Some persons with very feeble digestion 
can assimilate considerable quantities of sweet oil, while others whose 
general digestion seems much superior reject the oil. Trial in the 
individual case affords the only test ; we have seen excellent results 
achieved by giving one to two tablespoonfuls of sweet oil after meals. 
Often a dessertspoonful of whiskey may be advantageously given with 
the oil. A practical difficulty in the food management of constipation 
is that in most cases the condition is associated with feeble digestion, 
and that to digest food containing a large amount of indigestible matter 
is beyond the power of the patient. Very careful regulation of the diet 
in relation to the individual case is therefore essential. 

Medical treatment of constipation is to be avoided if possible ; very 
frequently, however, it is a necessary evil. The principles in the ad- 
ministration of drugs are, first, to avoid their employment as much as 
possible ; second, to use them, if at all, in small quantities regularly 
day by day, not allowing the patient to become constipated and then 
giving a purgative dose, but seeing that a passage from the bowels is 
obtained each day ; third, to change the drug or the combination of 
drugs at short intervals, so as to prevent the intestinal tract from be- 
coming accustomed to any one remedy. Enemata, glycerin or gluten 
suppositories, and similar contrivances, by acting upon the rectum and 
lower colon, produce faecal discharges ; but it is evident that they are 
much less effective than are laxatives in emptying the upper portion of 
the colon. Further, if continually used they produce an obtuseness of 



DISEASES OF THE INTESTINE. 



907 



the rectum which is unfortunate for the patient : hence their employment 
in chronic constipation should be limited to an occasional use as substi- 
tutes for laxatives, or for the purpose of obtaining a stool when the 
laxative has failed to act. 

Laxative drugs may be divided into the saline and the vegetable lax- 
atives. Among the saline laxatives must be placed the various natural 
mineral waters, too numerous for mention, which are so fashionable, but 
which are probably little better than artificial combinations. These 
combinations may vary indefinitely ; formulas 2 and 3 may be used, or, 
especially when there is a tendency to hepatic torpor, formula 19. On 
the other hand, a single saline, such as Rochelle, Epsom, or Glauber's 
salt, or magnesium citrate, may be administered by itself. The saline 
should always be given immediately upon getting out of bed in the 
morning, and should be taken in half a pint of water, hot or cold, accord- 
ing to the condition of the individual patient. 

Among the vegetable laxatives may be mentioned extract of cascara 
sagrada, solid or fluid, or in the form of an elixir ; compound liquorice 
powder; the so-called A.B.S. pill (aloin, gr. i- strychnine, gr. ; ex- 
tract of belladonna, gr. ; alcoholic extract of colocynth, given pref- 
erably in combination with extract of belladonna ; and preparations of 
senna, of resina podophylli, or of rhubarb. An alkaloid which has not 
been much used, but from which we have seen extraordinary results 
in chronic constipation, is eserine : it acts simply as a stimulant of 
the muscular coat of the bowels, and is especially valuable in elderly 
and other people in whom the intestinal muscular fibres are failing in 
power ; by its use the amount of laxative required may often be very 
greatly reduced. The ordinary dose is from one-fortieth to one-thirtieth 
of a grain, though one- twentieth may be given with impunity. The ob- 
jection to all laxative pills is to be found in the difficulty of varying the 
dose. Liquid preparations have the advantage over pills that the dose 
can be more readily changed and graded. An old combination whose 
use has given us more satisfaction than almost any other laxative is 
formula 20. 

Ordinarily it is desirable to give vegetable laxatives at night, because 
they require some hours for their action. When, however, constipation 
is obstinate, the best results are sometimes achieved by administering 
the vegetable laxative either after each meal or after the mid-day and 
evening meals. Cascara sagrada especially acts well when administered 
in this way. It is also better to give eserine rather by such method than 
in a single very large dose at bedtime. 

Much difficulty is sometimes encountered in the removal of impacted 
faeces. It is essential in all procedures to avoid as far as possible the pro- 
duction of irritation : hence great gentleness should be used and irritant 
drastic cathartics should be avoided. The mass should be attacked simul- 
taneously from above and from below. It is better to give small doses 



908 



DISEASES OF THE DIGESTIVE APPARATUS. 



of the laxative, repeated at short intervals, such drugs being selected as 
will especially cause free watery exudation and softening of the mass. 
Probably in the majority of cases the best results are to be obtained 
by giving calomel (one-quarter to one-half grain) and a saline (two 
drachms of Epsom or Glauber's salt, or two ounces of solution of mag- 
nesium citrate), so alternated that the patient shall take one or the other 
every two hours. Not more than eight grains of calomel in all should 
be administered. Combinations of vegetable drugs may also be used, 
and sometimes it is allowable to employ in such combination croton oil in 
doses of one-sixth of a drop. More generally useful is the old-fashioned 
"black draught" of senna and Epsom salt. When a very hard faecal 
mass can be felt in or above the rectum, it may be advisable, and is some- 
times necessary, to remove it with the finger, aided by a spoon or other 
appropriate instrument. 

Injections are to be freely used, and, when it is possible to get them 
above the faecal mass, or well into it, are often very efficient. In order 
to increase their softening power, they should be given as hot as can be 
borne. A warm thick mucilage of flaxseed or pure linseed oil is often 
comforting, and by lubricating the parts lessens the pain of delivery. 
In very severe cases it may be necessary from time to time to give the 
patient rest during the process of removal, so that the parts may recover 
from irritation. 



DISEASES OF THE LIVER. 



909 



CHAPTEE IV. 

DISEASES OF THE LIVER, GALL-BLADDER, AND BILE- DUCTS. 

DISEASES OF THE LIVER. 

MALFORMATION. 

Congenital and acquired deformities of the liver are to be recog- 
nized. The former, the lobulated liver, is usually the result of syphilis, 
and when it produces symptoms they are those of a fibrous hepatitis. 

Acquired deformities of the liver result from prolonged pressure ap- 
plied either to the waist, as from the corsets of women or the belts of 
men, or to the liver directly, by tumors or by the ribs in curvature of the 
spine. The extreme result of such pressure is a localized atrophy of the 
liver, with the production of a fibrous band, in which blood-vessels, lym- 
phatics, and bile- ducts are so obstructed that their peripheral branches 
become dilated. This band may serve as a sort of hinge, permitting such 
undue mobility of the separated portion of the liver that the latter is 
sometimes mistaken for an abdominal tumor. This error is especially 
apt to occur in those rare cases in which a portion of intestine over- 
lies the atrophied part of the liver. It is possible that a sensation of 
pressure or weight in the region of the liver may result, and that attacks 
of passive congestion of the dependent portion may produce pain, vomit- 
ing, and weakness. Jaundice rarely occurs. 

malposition. 

Displacement of the liver may exist at birth or be acquired later in 
life. Hernia of this organ and its transposition to the left side are con- 
genital. Acquired displacements are the result of pressure from below, 
as from an abdominal tumor, ascites, or meteorism, in which case the 
liver lies abnormally high. It lies unusually low when pressure is ap- 
plied from above, as from air or fluid in the pleural cavity or beneath 
the diaphragm, from an emphysematous lung, from deformity of the 
thorax, or from an intra- thoracic tumor. Such displacements are of 
more importance in calling attention to disease elsewhere than in causing 
disturbance in the function of the liver. 

A wandering liver is sometimes found, especially in middle-aged women 
who have borne children. It is probable that there are an elongated 
suspensory ligament and a lax abdominal wall. Muscular strain and 
tight lacing act as favoring canses. If productive of symptoms, it causes 
a sensation of weight, increased on exertion, and of pain, at times severe, 
referred either to the liver or to the right shoulder, or to both, and is some- 



910 



DISEASES OF THE DIGESTIVE APPARATUS. 



times accompanied with jaundice. Such patients are often neurasthenic 
or hysterical. In extreme cases the lower edge of the liver may lie in 
the right iliac fossa. The finger-tips may be pushed between the costal 
cartilages and the upper border of the liver. The outline of the ante- 
rior edge of the liver is easily traced, and the liver may be returned to 
its place. Such characteristics are usually sufficient to differentiate the 
wandering liver from ovarian, uterine, or renal tumors, or from cancer 
of the omentum. 

Treves has shown that this variety of displacement may be relieved 
by surgical treatment. 

FATTY LIVER. FATTY INFILTRATION OF THE LIVER. 

Fat may be present in the cells of the liver as a result of degenera- 
tion of the protoplasm or because of its accumulation in the normal pro- 
toplasm. The former condition is considered in the article on acute par- 
enchymatous hepatitis. The accumulation of fat, resulting in the fatty 
liver, is of clinical importance in explaining the occurrence of enlarge- 
ment of the liver, sometimes considerable, without significant symptoms. 

The liver is one of the storehouses of fat, which may remain within its 
cells for a longer or shorter time. The removal of fat from the liver 
takes place by its oxidation in the blood and its elimination with the 
bile. A fatty liver is likely to be found in persons eating excessively 
of fats, sugars, and starches. Sedentary habits, chronic alcoholism, ex- 
treme anaemia, wasting diseases, chronic diarrhoea, rickets, and malaria 
check the oxidation of fat, and thus favor its retention. 

There are no symptoms characteristic of a fatty liver. The associated 
disturbances, as loss of appetite, retching, nausea, vomiting, constipa- 
tion, or diarrhoea, though often attributed to obstruction of the portal 
capillaries by the surrounding liver-cells filled with fat, have no neces- 
sary dependence upon the latter condition. Such conditions as ascites 
and enlargement of the spleen are absent. Jaundice also is lacking. 
A sensation of fulness and weight, perhaps of epigastric pain, may be 
complained of. 

The anterior edge of the liver may lie as low as the navel, but is often 
palpated with difficulty from the usual presence of a large quantity of 
subcutaneous and subperitoneal fat. The fatty liver is also soft. 

If the physical examination indicates enlargement of the liver, its 
fatty nature is to be determined by a knowledge of the etiology of this 
condition. Hypertrophic cirrhosis is excluded by the absence of jaun- 
dice and by the failing resistance of the enlarged liver. An amyloid 
liver is hard, and the patient is cachectic, dropsical, and has albuminuria. 
The enlarged liver in leukaemia is dense, and the examination of the 
blood makes certain the diagnosis of this affection. The enlargement 
due to cancer is usually resistant and often irregular and sensitive ; jaun- 
dice is frequent, and cachexia is rapidly progressive. 



DISEASES OF THE LIVER. 



911 



Treatment. — The treatment of fatty infiltration of the liver is that 
of obesity. (See page 59.) Alcoholic drinks and tobacco should be 
absolutely forbidden, and a light diet strictly enforced. 

CONGESTION OF THE LIVER. 

This term, though frequently employed as explanatory of certain 
digestive disturbances, is often given exaggerated importance. Active 
and passive congestions are to be distinguished, the former occurring 
under physiological as well as pathological conditions, the latter the 
result of disease outside the liver. 

ACTIVE CONGESTION OF THE LIVER. 

Active congestion of the liver, due to the entrance of an increased 
quantity of portal blood, occurs after meals, and should be regarded as 
pathological if a person is a glutton or accustomed to highly seasoned 
food, alcoholic excess, and abstinence from physical exercise. Infection 
and traumatism are usually regarded also as causes. The congestion due 
to arrested catamenia, to ovarian or uterine irritation, or to suppressed 
hemorrhoidal flow is considered to be a vaso- motor disturbance. The 
symptoms usually attributed to congestion of the liver are those which 
may be due to a gastro- duodenal catarrh, and are accompanied by a sen- 
sation of weight and discomfort in the region of the liver, with an in- 
crease in the size of this organ. 

Treatment. — The treatment of acute congestion of the liver varies 
with the cause. If the latter be an infection, the treatment is that of the 
infection. Hepatic congestion, due to habitual over-eating, to alcoholic 
excess, or to other similar cause, is so universally associated with gastro- 
intestinal catarrh that the treatment is largely that of this disorder ; ordi- 
narily one-eighth to one-fourth grain of calomel may be given every two 
hours until free purgation is produced ; or, if this latter do not occur in a 
reasonable time, salines may be administered. In sthenic cases the diet 
should be reduced temporarily to a very low point, but when, as in alco- 
holics, the hepatic congestion is associated with general vital depression, 
animal broths or other easily digested nutritious food may be required. 

PASSIVE CONGESTION OF THE LIVER. 

Etiology. — Persistent obstruction to the outflow of blood through 
the hepatic vein produces passive congestion of the liver. Such obstruc- 
tion is most frequently caused by uncompensated valvular disease of the 
heart, or by disease or degeneration of the myocardium. Next in fre- 
quency are the causes of obstruction to the flow of blood through the 
lungs, as asthma, bronchitis, fibrous pneumonia, emphysema, atelectasis, 
and chronic pleurisy. Thoracic aneurism, mediastinal tumors, pleuritic 
effusion, or a deformed spine may obstruct the outflow of blood from the 
liver. Obstruction of the inferior vena cava by aneurisms and tumors 



912 



DISEASES OF THE DIGESTIVE APPARATUS. 



may produce a like result. Obstruction of the hepatic vein may be due 
to growths from its wall or to constriction from a periphlebitis. 

Limited portions of the liver may become passively congested by the 
obstruction or obliteration of branches of the hepatic vein by tumors, 
thrombi, or tight lacing. 

Morbid Anatomy. — At first the liver is symmetrically enlarged, 
purple in color, and diminished in consistency. The surface is smooth 
and shining. On section of the organ abundant blood escapes, and the 
dark -purple centres of the lobules are sharply differentiated from the 
paler peripheral portions. In the later stages the peculiar appearances 
have given rise to the terms nutmeg atrophy and red atrophy. The liver is 
diminished in size, is of a reddish-brown color, and is increased in con- 
sistency. The capsule is wrinkled and opaque. On section the surface 
is largely of a dark reddish-brown color corresponding to the central 
regions of the lobules, which are separated by gray or yellow lines 
or spots in the region of the portal vein. Pigment-granules in abun- 
dance and an increase of fibrous tissue are found on microscopical ex- 
amination. The spleen and pancreas are denser and darker than normal, 
and the radicles of the portal vein in the stomach and the intestine are 
dilated. 

Symptoms. — In the stage of enlargement there is a sensation of ful- 
ness and weight in the right hypochondrium ; there may be shortness of 
breath and pain on slight exertion, accompanied by a palpable resist- 
ance in the right hypochondrium and by epigastric pulsation, and the 
anterior border of the liver may be found below the navel. Consider- 
able changes in the apparent size of the liver at times rapidly follow 
active exercise. The heart-sounds may be readily heard on auscultation 
over the liver where it is superficial, provided the abdominal wall is 
lax. Percussion is usually less valuable than palpation in determining 
the lowermost outlines of the enlarged liver, from the ready transmission 
of intestinal resonance through its anterior edge. 

In the later stages of passive congestion digestive disturbances, as loss 
of appetite, nausea, vomiting, belching, and epigastric pain, become con- 
spicuous. Jaundice may be associated, but is usually slight, and in car- 
diac cases the combination of blue, from venous congestion, and of yellow, 
from jaundice, may produce a greenish tint of the skin. The urine and 
faeces are usually not indicative of obstruction to the outflow of bile. 
Dropsy, both ascites and anasarca, may eventually occur. The physical 
examination of the atrophied liver shows a considerable diminution in 
the area of hepatic dulness. 

Treatment. — The radical treatment of passive congestion of the liver 
is the removal of its cause. In most cases this is impossible, but it is 
often of the greatest importance to stimulate hepatic action. Hence the 
value of mercurials in chronic heart disease. Further, the hepatic conges- 
tion is frequently accompanied by congestion of the mucous membrane of 



DISEASES OF THE LIVER. 



913 



the stomach and intestines : hence saline purgatives, such as sodium 
phosphate, which unload the portal circulation and stimulate biliary 
secretion, are often of great service. 

There are so many cases of deranged hepatic function associated 
with congestion and a tendency to secretion of thick bile, and often 
to catarrhal inflammation of the ducts, that especial notice of their 
therapeutic management seems required. This condition is often enor- 
mously benefited by the treatment at Carlsbad, Vichy, and other saline 
and alkaline springs, a treatment which consists essentially in regu- 
lation of the diet and exercise and in the administration of large quan- 
tities of alkaline and saline waters. We believe that if the patient can 
be controlled at home, all that could be accomplished at Carlsbad can 
be reached by a parallel home treatment. 

In a large proportion of cases it is primarily necessary to reduce 
greatly the amount as well as to alter the character of the food taken. 
Sweets and all indigestible food should be forbidden. Even more dele- 
terious are rich foods : fats and substances cooked in them or dressings 
containing them should be excluded. Fish may be used freely, meats 
moderately. In no case should more food be taken than is just sufficient 
to sustain the weight. Complete abstinence from alcoholic drinks is 
essential. Begular exercise, carried to the point of physical tire but not 
to that of physical exhaustion, not interrupted by weather or untoward 
circumstances, and steadily and progressively increased as the patient's 
strength increases, forms an essential part of the management of the case. 
If the patient's strength suffices, the exercise should be sufficiently severe 
to produce free perspiration, and should be followed by a rub-down. In 
cases of robust men, physical training at the hands of a professional 
trainer is often very useful. When the strength is so reduced that active 
exercise cannot be taken, general massage should be used. 

On first rising in the morning the patient should take from two 
drachms upward of a mixture of sodium phosphate, sodium sulphate, 
and potassium iodide in eight ounces of hot water. (See formula 19.) A 
drachm of sodium phosphate, twenty grains of sodium bicarbonate, and 
ten grains of potassium bicarbonate should be administered in a half-pint 
of hot water one hour before the mid- day and the evening meal. These 
doses of salines are to be increased or decreased according to their effect, 
the object being to produce distinctly profuse but not too weakening 
watery passages. 

The occasional alternation of mercurial treatment for a short time with 
the saline and alkaline medication is often very advantageous. The mer- 
curial should be combined with ipecacuanha and euonymin, whilst in 
some cases the purgatively more active resin of podophyllum may be 
added. In many cases the giving of a pill of calomel and ipecacuanha 
once a week is very beneficial. Nitrohydrochloric acid is frequently 
very serviceable : it may be exhibited during the saline treatment, but 

58 



914 



DISEASES OF THE DIGESTIVE APPARATUS. 



not near the time of the administration of mercurials. It is essential 
that the acid be freshly made, of a distinct reddish color, and be admin- 
istered after meals in doses of from four to eight drops, well diluted in 
sweetened water, and taken with proper precautions for the protection 
of the teeth. The nitrohydrochloric acid should always be diluted at 
the time of its taking, since by rearrangement of its constituents diluted 
nitrohydrochloric acid in a little time becomes a mixture of dilute nitric 
and dilute hydrochloric acid. Nitrohydrochloric acid has been used in 
India to a considerable extent in the form of baths, but the advantages 
do not seem to equal the inconvenience. In many cases of chronic he- 
patic congestion the local application of nitrohydrochloric acid (one 
part to from twenty to thirty) by means of a saturated cloth covered 
with oiled muslin is very advantageous. The strength of the solution 
should be sufficient to produce a local sense of warmth, with prickling, 
but not to cause much irritation even after some hours of contact. The 
application usually provokes local sweating, acts, perhaps, as a counter- 
irritant, and probably yields products to absorption. 

Ammonium chloride is a valuable remedy, which may be substituted 
for the alkaline mixture heretofore recommended before meals, or may be 
added to the alkaline treatment. From twenty to forty grains should be 
given in a tumbler of water two hours before eating, or two hours after 
meals if the patient is taking the alkaline mixture. 

In continuing cases of hepatic congestion vegetable cholagogues are 
often serviceable from time to time. We have known good effects 
obtained by the use of a mixture of the fluid extracts of sanguinaria and 
leptandrin, each two parts, with one part of the fluid extract of podo- 
phyllum ; dose, from five to ten drops after meals, according to the effect 
upon the bowels. Extract of taraxacum has not seemed to us efficient. 

PERIHEPATITIS. 

Inflammation of the peritoneal capsule of the liver may be either 
acute or chronic, the former of extreme clinical importance, and, as 
subphrenic abscess, made especially conspicuous by Ley den, Mason, and 
others, the latter of but little significance. Either may be part of a gen- 
eral peritonitis, or of a peritonitis limited to the immediate vicinity of 
the liver. 

ACUTE SUPPURATIVE PERIHEPATITIS. 

Definition. — A suppurative inflammation of the peritoneal capsule 
of the liver, resulting in the accumulation of pus between the diaphragm 
and the liver, the more common variety of the subphrenic abscess, or in 
the presence of air or gas and pus in the same region, subphrenic pyo- 
pneumothorax. 

Etiology. — Acute suppurative perihepatitis may be due to direct 
violence, especially a penetrating wound. It more commonly results 
from a perforating ulcer of the stomach or duodenum, abscess or echi- 



DISEASES OF THE LIVER. 



915 



nococcus of the liver, suppurative inflammation of the biliary passages, 
especially of the gall-bladder, appendicitis, pancreatitis, or abscess of 
the lung, spleen, or kidney. Bemoter causes are to be found in inflam- 
mation of the uterus and tubes, perforation of the oesophagus, cancer of 
the stomach and oesophagus, and chronic tuberculosis of neighboring 
parts. 

Morbid Anatomy. — The peritoneum covering the liver and the cor- 
responding surface of the diaphragm is thickened, opaque, without lustre, 
and covered with a fibrinous false membrane. The general peritoneal 
cavity is separated from that portion overlying the liver by fibrinous ad- 
hesions either to the left or to the right of the suspensory ligament, more 
frequently to the latter, according to the cause of the perihepatitis. The 
abscess may hold a quart or more of pus alone, or the pus may be mixed 
with air or gas, especially when perforation of the stomach or duodenum 
is the cause. When bile is mixed with the pus the latter is likely to be 
of a yellow ochre color and to contain bilirubin crystals. The pus may 
be fattily degenerated and crystals of fat acids be found. 

Symptoms.— Suppurative perihepatitis being secondary to diseased 
conditions elsewhere, its onset may be sudden or gradual, the former being 
particularly the case when perforation of the stomach or duodenum is the 
cause. The rapidly progressing cases are those in which the symptoms 
suggest a circumscribed peritonitis in the vicinity of the liver. Severe 
pain, often of sudden onset and increased on prolonged inspiration, and 
tenderness, are present in the epigastrium or the right hypochondrium. 
There is a continuous fever, sometimes preceded by a chill. Loss of 
appetite, nausea, and vomiting usually occur, and there may be slight 
jaundice. There is increased frequency of respiration. The physical 
signs closely resemble those resulting from pleurisy, which disease is 
sometimes associated with perihepatitis. They vary in degree according 
to the quantity of exudation or gas present. Distention of the right 
hypochondrium and epigastrium and immobility of the corresponding 
intercostal spaces are conspicuous. The degree of dulness on percus- 
sion varies in like manner, and dulness may be present as high as the 
fourth rib, varying with change of position. The lower line of hepatic 
dulness may be found on a level with the navel, where the anterior edge 
of the liver is then to be felt. There is an absence of respiratory sounds 
and vocal fremitus in the region of dulness, whereas the respiratory 
murmur in the upper part of the chest is exaggerated. The presence 
of air or gas beneath the diaphragm produces similar physical signs, 
with the exception that a tympanitic region overlies the dull area. 

The course of suppurative perihepatitis may be prolonged over a 
period of months, and is then characterized by an irregular range of 
temperature, with progressive emaciation and debility. The pus may be 
absorbed, or be discharged into the pleural cavity, lung, stomach, or in- 
testine, or through the abdominal wall, or even below Poupart' s ligament. 



916 



DISEASES OF THE DIGESTIVE APPARATUS. 



Obstruction of the hepatic or portal veins or of the inferior vena cava 
may result from thrombosis or periphlebitis, with the production of con- 
gestive atrophy of the liver, ascites, or oedema of the lower extremities. 
The extra-hepatic bile- ducts may be compressed by the cicatricial tissue, 
and persistent jaundice follow. 

Diagnosis. — Etiology is of especial importance in the diagnosis. 
The rational and physical signs may be insufficient to determine whether 
the seat of the exudation is above or below the diaphragm. Absence of 
cough and of expectoration and slight displacement of the heart are in 
favor of perihepatitis. Bulging of the hypochondrium and extreme de- 
pression of the liver are unlikely to occur in pleurisy. The diagnosis is 
eventually to be made by exploratory puncture in the seventh or eighth 
interspace in the axillary line. According to Pfuhl, fluid below the dia- 
phragm escapes more freely during inspiration, the reverse being the case 
in pleurisy. The presence of bile-pigment would favor the subphrenic 
seat of the exudation. 

Prognosis. — Acute perihepatitis, when fibrinous in character, may 
terminate favorably in a short time. Recovery from the suppurative 
variety may also take place by absorption or spontaneous evacuation of 
the pus. The latter is always a grave affection, and often fatal when 
representing a peritonitis from perforation. A considerable diminution 
in the mortality is likely to result from surgical treatment. 

Treatment. — The early treatment of an acute perihepatitis should be 
that of a local peritonitis. After the formation of pus, surgical evacuation 
and drainage are strongly indicated. 

CHRONIC PERIHEPATITIS. 

Although chronic perihepatitis is of but little clinical importance, it is 
of relatively frequent occurrence. When circumscribed it represents the 
result of prolonged pressure in certain trades or from articles of dress, or 
it may be due to localized growths of cancer or syphilis or to the extension 
of a pleurisy. The affected peritoneal capsule of the liver is thickened 
and opaque. Fibrous adhesions may unite the liver to the diaphragm, 
stomach, colon, or abdominal wall, and the contraction of the fibrous 
tissue may cause atrophy of the liver and narrowing or obliteration of its 
ducts and vessels. When extreme, as a sequel of suppurative perihepa- 
titis, it may be of serious importance from its mechanical effects upon the 
liver and its vessels and ducts. 

ACUTE YELLOW ATROPHY OF THE LIVER. ACUTE PAREN- 
CHYMATOUS HEPATITIS. 

Etiology. — This affection is of rare occurrence, and is more common 
among women, especially in the latter half of pregnancy, than among 
men. It usually occurs in adults, though it may be present at any period 
of life. Intense mental excitement and alcoholic excesses are mentioned 



DISEASES OF THE LIVER. 



917 



as causes, and it has been found in the course of acute infectious diseases, 
as typhoid and relapsing fevers, diphtheria, pyseinia, and septicaemia. 
The importance of infection in etiology is suggested also by the frequent 
discovery of bacteria in the diseased liver and by the occurrence of a 
number of cases in a given locality within a short time. Phosphorus 
poisoning produces a similar alteration of the cells of the liver, and it 
may occur as a secondary condition in the course of severe jaundice or 
of fibrous hepatitis. 

Morbid Anatomy. — The liver is more or less enlarged at the outset, 
and in phosphorus poisoning may remain so until death. As a rule, it 
eventually becomes decidedly diminished in size and flattened. It is 
of dirty-yellow color and firm consistency, though flaccid. On section 
the color may be uniformly yellow and opaque, and the lobular regions 
indistinct, or there may be alternate patches of red and yellow. Crystals 
of leucin and tyrosin may form white specks after prolonged exposure of 
the cut surface to the air. Microscopical examination shows extensive 
and extreme fatty degeneration of the liver-cells, the fat having been 
absorbed from the red portions of the liver. The interstitial tissue is 
slightly infiltrated with leukocytes, and clumps of cells are to be found, 
which are regarded as new-formed bile-ducts or bands of liver-cells. 
Crystals of leucin, tyrosin, and bilirubin are also to be seen. 

The spleen is hyperplastic. There is fatty degeneration of the epithe- 
lium of the kidneys and of the gastric glands, of the heart, and sometimes 
of the voluntary muscles. Small hemorrhages are present throughout 
the body, and the tissues are stained yellow. The pleural and pericar- 
dial cavities may contain an excess of fluid. 

Symptoms. — The characteristic symptoms of acute yellow atrophy are 
usually preceded by loss of appetite, nausea, vomiting, belching, irregu- 
lar stools, tender epigastrium, headache, prostration, and slight jaundice. 
The symptoms then suddenly become severe. There is constant vomit- 
ing, eventually of a bloody fluid. There are intense headache, restlessness, 
delirium, convulsions, and coma. Nasal, gastro-intestinal, urinary, and 
cutaneous hemorrhages may occur, and abortion with excessive flowing is 
likely to take place in pregnant women. The temperature is not espe- 
cially elevated until shortly before death, when it may reach 104° F., 
although it may be subnormal at this time. The pulse, slow at the outset, 
becomes rapid and feeble. The area of hepatic dulness rapidly dimin- 
ishes, and may wholly disappear, although Gerhardt reports a case in 
which there was no change in dulness despite the atrophy of the liver, 
in consequence of adhesions between the liver and the abdominal wall. 
According to Riess, there is tenderness in the right hypochondrium even 
when the patient is comatose. 

The urine is diminished in quantity, and its secretion may be sup- 
pressed. It is bile-stained, acid, sp. gr. 1012 to 1030, moderately albu- 
minous, and contains bile-pigment, bile-acids, and hyaline and fatty casts. 



918 



DISEASES OF THE DIGESTIVE APPARATUS. 



Urea is greatly diminished or absent. Leucin and tyrosin are usually 
present, and should be sought for, if necessary, in the urine treated with 
acetic acid and evaporated. 

Diagnosis. — Acute yellow atrophy is to be suspected on the sudden 
onset of restlessness, delirium, and convulsions in a case of apparent 
simple jaundice. The great diminution or the absence of urea, the pres- 
ence of leucin and tyrosin in the urine, perhaps of bacteria in the blood, 
and the diminution in the size of the liver, confirm the diagnosis. Phos- 
phorus poisoning cannot be distinguished solely by the symptoms. The 
absence of leucin and tyrosin from the urine in poisoning, and the other 
differences which have been alleged to be diagnostic by various writers, 
have been proved not to be constant, and cannot be depended upon. 
The enlargement of the liver is more persistent in the poisoning, but 
without a history poisoning cannot be more than suspected unless phos- 
phorus be recognized chemically in the contents of the stomach or intes- 
tines, or in the urine in a lower degree of oxidation than phosphoric acid. 

The symptoms of parenchymatous hepatitis occurring in obstructive 
jaundice and fibrous hepatitis are to be differentiated from those due to 
acute yellow atrophy by the rapid progress of the latter. 

Prognosis. — Although recovery from the severer forms of paren- 
chymatous hepatitis has been reported, the prognosis of this disease is 
almost invariably fatal, death usually occurring in the course of two or 
three days after the onset of the severer symptoms, and within a fort- 
night from the beginning of the attack. Exceptionally the disease has 
extended over a period of two months. 

Treatment. — There is no known specific treatment. Symptoms are 
to be met as they arise. 

SUPPURATIVE HEPATITIS. ABSCESS OF THE LIVER. 

Etiology. — Abscesses of the liver are due to the entrance into this 
organ of pyogenic bacteria or amoebae coli, rarely of actinomyces or 
coccidia, and sometimes of a chemical agent. The irritant may enter 
directly by means of a wound or by means of the blood-vessels or the 
bile-ducts. 

Traumatic abscesses are due to traumatism and infection, and Dab- 
ney has shown that abscesses of the liver rarely arise from disease of 
the bones or of parts of the body other than those intimately connected 
with the liver. Embolic and thrombotic abscesses follow the admission 
of the pyogenic irritant by means of the blood-vessels, and infectious 
emboli are brought from the inflamed radicles of the portal vein in the 
parts of the intestine affected in appendicitis, dysentery, and piles ; but 
typhoid ulcers rarely serve as a cause of hepatic abscess. Emboli may 
also be transferred from abscess of the spleen and from the inflamed 
umbilical vein of the new-born child. Infectious embolism of the hepatic 
artery, however, rarely causes hepatic abscess except in ulcerative endo- 



DISEASES OF THE LIVER. 



919 



carditis and in pulmonary gangrene. Osier and Eoss have suggested 
that a bland embolus carried from an aneurism of the hepatic artery 
may produce abscess of the liver by the presence of pathogenic agents 
in that part of the liver to which the embolus is carried. An infectious 
embolus from a body vein may enter the hepatic vein by regurgitation 
and act as a cause of abscess. 

Abscesses of the liver of vascular origin may result as well from 
thrombosis as from embolism, the infecting thrombus being directly 
continued from the inflammatory or ulcerative process in the radicles 
of the portal vein or from the umbilical vein into the liver. 

The irritant invades the liver through the bile- ducts in cases of sup- 
purative cholangitis continued through the common bile-duct from the 
intestine. Abscesses are then more likely to result if gall-stones, para- 
sites, or foreign bodies are present in the bile-ducts. 

It is probable that abscesses occurring in the tropics are due to the 
causes above mentioned, and their frequency may be accounted for by 
the prevalence of dysentery in the tropics, especially since Kartulis, 
Councilman, and others have shown the relation of the amoeba coli to 
dysentery and abscess of the liver. Furthermore, Kiener and Kelsch 
have shown that dysentery was present with hepatic abscess in eighty- 
five per cent, of three hundred and fourteen cases. 

Morbid Anatomy. — The liver is usually enlarged symmetrically, and 
the outside may show no appearances suggestive of pus. On the other 
hand, the presence of opaque, yellowish-white, rounded patches covered 
with false membrane, and yielding to the touch, indicates the existence 
of subjacent abscesses. The latter are single or multiple. 

Single abscesses generally result from the confluence of multiple ab- 
scesses. According to Waring' s figures, the abscess is limited to the 
right lobe in two-thirds of the cases, and usually lies near the convexity. 
It may contain several quarts of pus. Its cavity may be crossed by bands 
and cords, the remains of the partitions between smaller abscesses ; in 
acute cases the wall is shreddy, not sharply defined. The wall of the 
chronic abscess is grayish white, dense, and circumscribed. The con- 
tents are an opaque, viscid fluid, of a yellow or reddish color, containing 
leukocytes, fat- drops, granular material, and crystals of bilirubin. The 
presence of hooklets, amoebae, actinomyces, or coccidia indicates the 
cause of the abscess concerned. 

Multiple abscesses may be found throughout the liver, are often in 
groups, and as many as fifty have been observed. They may be as large 
as walnuts, sharply defined, irregularly rounded, or lobulated. The 
walls and contents resemble those of the solitary abscess. A thrombotic 
or embolic origin is indicated by the presence of arborescent patches of 
necrosis and of puriform thrombi in the branches of the portal vein. 
Abscesses originating from the bile- ducts are associated with dilated 
ducts containing a green pus. 



920 



DISEASES OF THE DIGESTIVE APPARATUS. 



As the abscess reaches the surface of the liver, adhesions are formed 
between this organ and adjacent structures, as the diaphragm, the stomach 
or the intestine, the renal pelvis, or the abdominal wall. Perforation 
may occur and the pus be evacuated, escaping into the peritoneal, 
pleural, or pericardial cavity, and perhaps finding an outlet at some 
point remote from the liver. 

Solitary and small abscesses are at times transformed into cysts with 
viscid contents in which cholesterin is often found, or the pus, becoming 
inspissated, forms a cheese-like mass or a calcified nodule enclosed within 
a dense fibrous capsule. 

Symptoms. — There may be no symptoms calling immediate attention 
to abscess of the liver, its presence being first suggested by the escape 
of pus from some other organ, or being made evident at a post-mortem 
examination. Even suggestive symptoms of suppurative hepatitis may 
be wholly obscured by those of the disease to which it owes its origin. 
The patient loses flesh and strength, is likely to be troubled with nausea 
or vomiting, and complains of epigastric distress. Jaundice is often 
absent, or slight, and, if considerable, may be due to pressure of the 
abscess upon the larger bile- ducts. Late in the course of the disease 
the patient at times becomes mildly delirious, and still later coma often 
supervenes. Pain in the region of the liver is usually present either as 
an early or as a late symptom. It occurs as the suppuration nears the 
surface, and is referred perhaps to the seat of the abscess or to the 
right shoulder. The latter localization is to be explained by the transmis- 
sion of irritation from the branches of the phrenic nerve in the capsule 
of the liver and in the suspensory ligament to the fourth cervical nerve, 
which also receives branches from the shoulder. The sensation of pain 
is thus capable of being referred through the central nervous system to 
a point remote from its origin. 

The presence of suppuration is especially indicated by the prolonged 
elevation of temperature, although this may be so slight in cases of 
chronic abscess as not to be especially significant. More frequently 
exacerbations and remissions of temperature are present, with a rise per- 
haps as high as 105° F. The elevation of temperature, if continuous, 
with evening exacerbations, often suggests typhoid fever or tuberculosis, 
and if associated with chills and sweating, especially when these are at 
regular intervals, gives rise to the thought of malaria. As the disease 
progresses, a sudden fall of temperature often results from the evacua- 
tion of an abscess, and a prolonged lowering of the temperature not in- 
frequently occurs some time before death. The frequency of the pulse 
and respiration is in accord with the variations of temperature. The 
pulse is weak, and the respiration often rapid and painful, and accom- 
panied by a dry cough when the surface of the diaphragm is inflamed. 
If the abscess breaks into the lung, its contents, usually of a reddish 
color, according to Osier resembling anchovy sauce, have given evidence. 



DISEASES OF THE LIVER. 



921 



on microscopical examination, of the presence of amoebae. The action 
of the bowels is irregular. The stools are not likely to become clay- 
colored, but contain abundant pus if the abscess empties into the bowel. 
The source of this pus is made apparent by the discovery of hooklets, 
amoebae, or other evidence of its parasitic origin. The urine is not es- 
pecially noteworthy, except in those cases where the abscess empties 
into the urinary tract. 

Enlargement of the liver, which is usually present, is made evident 
both by percussion and by palpation, and often becomes apparent on 
inspection, especially when the patient is in the upright position. The 
enlargement is irregular if the abscess projects above the surface, and 
may be indicated by a sharply defined area of thoracic dulness, convex 
upward when the projection is from the upper part of the right lobe. 
The size of the liver is in the main in proportion to the quantity of 
pus present. It is sometimes sufficiently enlarged to cause ascites from 
pressure on the portal vein, or anasarca from pressure on the inferior 
vena cava. The upper border of hepatic dulness may extend to the 
second rib in front and to the spine of the scapula behind, and the an- 
terior edge of the liver be found near the crest of the ilium. Crepita- 
tion or fluctuation is sometimes recognized on palpation, and is indica- 
tive either of a localized peritonitis or of the seat of the abscess. The 
liver is tender to the touch when the anterior surface is inflamed, and 
the abdominal wall then becomes tense when palpation is attempted. 
The spleen is moderately enlarged. 

The symptoms of abscess of the liver may continue for a period 
of years, — five in the case reported by Ewald, — or a fatal issue may be 
reached in the course of a few weeks. The average duration of fatal 
cases is from six weeks to three months. The smaller abscesses tend 
to coalesce, thus forming the large abscess, which extends towards the 
surface of the liver, with the eventual spontaneous evacuation of the 
pus. Immediate relief to the symptoms is then likely to occur ; if, 
however, the drainage is defective and the destructive process continues, 
with or without the complications of hemorrhage, embolism, peritonitis, 
or septicaemia, permanent fistulae may become established, with perhaps 
the eventual occurrence of amyloid disease. 

Diagnosis. — Time is an important factor in the diagnosis of suppu- 
rative hepatitis, which is based upon the association of protracted con- 
tinuous or intermittent fever, painful, perhaps tender, enlargement of 
the liver, leukocytosis, and a thorough appreciation of the etiology of 
suppurative hepatitis. The most important element in the diagnosis is 
the aspirator ; but the exploratory puncture may not reach the abscess, 
or the pus may be too thick to flow through the needle. If an abscess is 
suspected, repeated punctures should be made, if necessary, the places 
of election being tender or yielding spots in the enlarged liver below 
the costal cartilages, the seventh right intercostal space in the axillary 



922 



DISEASES OF THE DIGESTIVE APPARATUS. 



line, and at this level in front or behind if dulness extends farther up. 
The necessity for aspiration is greater than its danger, although there 
may be profuse hemorrhage while the needle remains in the liver. 

Malaria is to be differentiated by the more typical recurrence of 
the chills, the considerable enlargement of the spleen, the successful 
treatment with quinine, and the absence of the parasites of malaria. 
Pulmonary tuberculosis, which simulates hepatic abscess by cough and 
hectic, is to be excluded by the results of physical examination. Em- 
pyema may be suggested by the fever and physical signs, but in hepatic 
abscess dulness is higher in front than behind, while in empyema the 
retracted lung lies along the spine and at the upper part of the thorax. 
Incarcerated gall-stones in the large bile- ducts at times are mistaken for 
suppurative hepatitis, but in gall-stones the pain is usually more severe 
and the jaundice more extreme and constant, whilst the elevation of 
temperature is often slight and recurs with the attacks of pain. The 
echinococcus cyst may present the physical characteristics of a large 
abscess, but its growth is slow, afebrile, as a rule, and without disturb- 
ing symptoms, except those of mechanical origin. 

Prognosis. — Large abscesses or many small abscesses of the liver are 
always dangerous, the mortality in cases not treated surgically being as 
high as eighty per cent. The possibility of recovery from small single 
abscesses by absorption or calcification has already been mentioned. Ke- 
covery from more extensive suppuration is possible only by the efficient 
evacuation of the pus. It is stated that one-half of the cases of evacua- 
tion of the abscess through the lungs or gastro-intestinal canal recover, 
and the mortality may be as low as thirty per cent, in cases treated 
surgically. 

Treatment. — Septic abscesses of the liver are usually not amena- 
ble to any treatment, nor is there any known method of checking 
the formation of the primary abscess ; the medical treatment must, 
therefore, be symptomatic and palliative. The diet should be largely 
or altogether liquid or semi-solid, unirritating, but nutritious and sup- 
porting. 

The surgical treatment consists in complete evacuation of the pus and 
drainage of the cavity, for aspiration is of little value save as a means of 
diagnosis. The decision of the time at which the cavity shall be opened 
is often a point of great nicety : on the one hand, there is danger of the 
rupture of the abscess into the peritoneum or some other vital part, and 
also of exhaustion of the patient ; on the other hand, there is the reason- 
able expectation that the formation of adhesions between the liver and the 
abdominal wall will greatly favor safe evacuation. When an abscess has 
discharged through an internal organ, such as a lung or the intestine, the 
case should usually be left to nature, unless increasing hectic fever and 
failure of strength point strongly towards approaching death, in which 
case the effect of a counter-opening may be tried. 



DISEASES OF THE LIVES. 



923 



FIBROUS HEPATITIS. CHRONIC INTERSTITIAL HEPATITIS. 

CIRRHOSIS. 

Etiology. — Fibrous hepatitis is a disease more frequent in man than 
in woman. Although usually occurring in the adult, Howard and Hat- 
field have collected a considerable number of cases among children, and 
it may be present in the foetus. It is generally considered to be the result 
of the continued presence in the liver of an irritant brought by the blood- 
vessels, especially the portal vein, or entering through the bile-ducts or 
directly from the surface. In nearly two-thirds of the cases the irritant 
is alcohol, especially that obtained from the fermentation of grains and 
potatoes. An unknown predisposing cause on the part of the individual 
is also probable, since many persons addicted to the excessive use of 
alcohol are free from this disease. The undue use of strong wines and 
beer sometimes gives rise to fibrous hepatitis. It is asserted that spices, 
coffee, ptomaines, phosphorus, arsenic, and antimony may act as causes, 
— a view based rather upon experiments than upon clinical evidence. 
Acute infectious diseases, as malaria, typhoid fever, scarlatina, cholera, 
and dysentery, are also regarded as causes. If they are to be admitted as 
such, their importance must be slight, owing to the rarity of fibrous 
hepatitis in comparison with the frequency of these diseases. Chronic 
infectious diseases, especially syphilis, whether congenital or acquired, 
produce cirrhosis, and miliary tuberculosis, rickets, and gout are main- 
tained to be of etiological importance. Welch, in his observations on 
the pigmented liver of coal-miners, calls attention to the possible signifi- 
cance of a mechanical irritant, as coal-dust. Botkin maintains that fibrous 
hepatitis may result from obliteration of the portal vein, and Eichhorst 
favors the etiological importance of old age in producing an arterio- 
sclerosis with resulting atrophy, as in the kidney. The nutmeg atrophy 
from continued obstruction in the course of the hepatic vein causes a 
slight degree of fibrous hepatitis. 

The importance of the bile-ducts in the production of fibrous hepatitis 
is seen in cases of chronic cholangitis. This affection in turn may be the 
result of gall-stones, tumors, or tuberculosis, or of congenital obstruction, 
stenosis, or obliteration of the bile- ducts. 

Fibrous hepatitis proceeds from the surface of the liver in consequence 
of a perihepatitis when a chronic inflammation of the capsule exists, 
either limited or part of a chronic peritonitis. 

Morbid Anatomy. — Chronic fibrous hepatitis is characterized by 
an increase of the connective tissue of the liver, usually associated with 
a destruction of liver-cells, and resulting in a shrinkage of the organ. 
Sometimes the liver-cells are not destroyed, the fibrous tissue does not 
shrink, but an enlargement of the liver results. Two varieties of fibrous 
hepatitis are thus to be recognized, — the one hypertrophic, the other 
atrophic, cirrhosis. The former is manifested by a symmetrically en- 



924 



DISEASES OF THE DIGESTIVE APPARATUS. 



larged liver, weighing perhaps eight pounds, in which a new formation 
of connective tissue is more directly connected with the bile- ducts, and 
the liver-cells are either unaltered or fattily infiltrated. 

In atrophic cirrhosis the liver, at first increased in size, may become 
so shrunken as to weigh but a pound. The atrophy is asymmetrical, and 
produces various degrees of deformity. Granules and nodules from the 
size of a pin's head upward project from the surface, and according to 
the predominance of larger or smaller projections the terms "granular 
liver,'' " hobnailed liver," and "lobulated liver" are applied. The cap- 
sule is thickened and opaque. The color varies from gray to a tawny yel- 
low (xippoq). whence the term " cirrhotic." The yellow shades of color 
are dependent upon the presence of fat and biliary coloring matter. The 
consistency of the liver is increased, and is often compared to that of 
leather. The growth of fibrous tissue proceeds rather from the vicinity 
of the portal vessels than from the neighborhood of the bile-ducts, and its 
shrinkage causes rather narrowing and obliteration of the former than 
obstruction of the latter. These may be affected to a certain degree, and 
clusters of cells indicative of new-formed bile-ducts may be seen. 

The spleen is usually enlarged, and may become thrice the normal 
size. Its enlargement is chiefly the result of the portal obstruction, and 
is the greater the later the stage of the disease. The enlargement may be 
in part due to the cause of the cirrhosis, since the former is sometimes 
found before any considerable degree of ascites is present. If the cap- 
sule is thickened or has undergone marked atrophy, decided enlarge- 
ment is prevented. The peritoneum is thickened and opaque, sometimes 
granular, and the mucous membrane of the stomach and the intestines 
is swollen and its blood-vessels dilated. 

Owing to the obstruction to the flow of portal blood through the liver, 
the radicles of the portal vein are distended, and their anastomoses with 
the peripheral veins of the body dilated. The latter are to be found at 
the junction of the oesophagus and the stomach, along the course of the 
large intestine, in the lower part of the rectum, and in the retroperi- 
toneal plexus of veins in front of the spine. Dilatation of the anasto- 
mosing branches in the suspensory and round ligaments also takes place, 
and is sometimes continued to the cutaneous veins around the navel, 
forming the caput Medusae. Branches of the internal mammary and epi- 
gastric veins may also become dilated and tortuous. 

Symptoms. — There are no symptoms characteristic of the early stages 
of cirrhosis of the liver. As the disease advances and the destruction 
of the liver- cells and the obstruction of the portal circulation take 
place, disturbances of function appear, and sometimes develop with 
great rapidity. The obstructed portal circulation produces a chronic 
gastro- intestinal catarrh, which is manifested by loss of appetite, belch- 
ing, nausea and vomiting, flatulence, and irregular action of the bowels. 
After a while hemorrhages are likely to occur, either as nosebleed or 



DISEASES OF THE LIVER. 



925 



as bleeding piles, or, in consequence of the portal congestion, the blood 
may regurgitate from the oesophagus, be vomited from the stomach, or 
escape with the stools. The attacks of hemorrhage are often repeated, or 
a large quantity of blood is lost in a single attack, and in consequence 
persistent ansemia is the frequent result. Such hemorrhage may be the 
first symptom to excite suspicion of the existence of cirrhosis, and its 
occurrence may afford temporary relief to the digestive disturbances de- 
pendent upon portal stagnation. Cutaneous hemorrhages, which usually 
take place late in the disease, are dependent rather upon degenerative 
changes in the walls of the blood-vessels than upon mechanical obstruc- 
tion. 

Ascites eventually develops, and may be the first symptom to attract 
the patient's serious attention. It is due to the obstruction of the portal 
circulation, is usually slow in development, unless thrombosis of the 
portal vein occurs, and may result in the presence of several gallons of 
fluid. The characteristics of such fluid will be found in the article on 
ascites. The larger its quantity the greater the discomfort, chiefly mani- 
fested by the increased intra-abdominal pressure, which may vary from 
hour to hour or from day to day in consequence of the absorption of 
fluid, the action of medicines, the escape of gas from the stomach or in- 
testines, or the occurrence of hemorrhage. If the fluid is removed by 
tapping, it usually reaccumulates within a few weeks, the more rapidly the 
more frequent the withdrawal. Jaundice is not an essential symptom of 
cirrhosis of the liver, although slight and perhaps recurrent attacks may 
occur. These are due rather to causes outside the liver, especially catarrh 
of the common bile-duct, than to pressure upon the bile-ducts within the 
liver. 

The progressive destruction of the liver-cells results in more extreme 
disturbances of nutrition. Emaciation becomes conspicuous, and the 
patient is weak and irritable. The breathing is rapid and labored, 
partly in consequence of ascites. The heart is weakened, and the pulse 
correspondingly feeble. (Edema of the skin, especially of the feet and 
legs, the scrotum, and the dependent portions of the abdomen, occurs, as 
the result partly of the enfeebled heart- action and partly of the portal 
obstruction. Eventually hydrothorax and oedema of the lungs are likely 
to take place. Finally, profound disturbance of the nervous system, as 
delirium, convulsions, and coma, immediately precedes death. 

Evidence of emaciation is seen especially in the face, arms, and hands, 
which strikingly contrast with the bloated portions of the abdomen and 
legs. The skin is pale, of a dirty- gray color ; at times it shows a yel- 
lowish tint from complicating jaundice. The tongue is usually dry and 
coated. The abdominal distention, unless extreme, varies with the posi- 
tion of the patient. The navel protrudes. The veins at the dependent 
portions and perhaps near the navel are conspicuous. (See also Ascites.) 
The physical examination of the liver usually becomes possible only 



926 



DISEASES OF THE DIGESTIVE APPARATUS. 



when the ascites is relieved by tapping. The outlines of the shrunken 
liver then may be determined, and its granules or lobules often be felt 
owing to the lax condition of the abdominal wall and the excessive mo- 
bility of the liver when not adherent. The enlarged spleen is also more 
readily recognized after the fluid is removed, although it is often possible 
to determine its outlines by percussion and palpation if the patient can 
lie on the right side. 

Diagnosis. — In the early stages of cirrhosis the diagnosis is impos- 
sible. When hemorrhage from the stomach or bowels is the first impor- 
tant symptom, fibrous hepatitis is to be suspected if there is an alcoholic 
history and there are no symptoms pointing to ulcer of the stomach or 
bowels. A similar history with or without hemorrhage but with the 
development of ascites also makes probable cirrhosis. The recognition 
by physical signs of a granular or nodular atrophied liver establishes 
the diagnosis. Previous to the withdrawal of fluid from the abdomen it 
is often impossible to recognize fibrous hepatitis, since a correct explana- 
tion of the cause of ascites has frequently been made only after a lapa- 
rotomy or on the post-mortem table. In brief, the existence of cirrhosis 
of the liver is most likely to be made when the liver can be physically 
examined. 

Prognosis. — Fibrous hepatitis when capable of recognition is likely 
to prove soon fatal, death taking place within a few months or a year. 
On the other hand, patients have lived for years after the occurrence 
of hemorrhage and ascites, and considerable degrees of cirrhosis of the 
liver have been found after death in persons who had been supposed 
to be free from liver disease. A guarded prognosis is therefore to be 
made until the duration and severity of the symptoms, and the ability 
of the patient to preserve flesh and strength, have been thoroughly ascer- 
tained. 

Treatment. — In most cases of cirrhosis of the liver the primary in- 
dication is the withdrawal of alcohol and all stimulating or irritating 
highly seasoned foods ; in the case of tavern-keepers and bartenders who 
were unable to or would not cease using alcohol, we have known the 
substitution of hard cider for all other drinks apparently to protract life 
for a great length of time. Although in the advanced stages of the dis- 
ease no medical treatment can effect anything, in the beginning it is the 
duty of the practitioner by the use of the remedies already spoken of 
under the head of chronic hepatitis to endeavor to bring about hepatic 
resolution. During the stage of contraction the treatment must be purely 
symptomatic. The patient's strength should be sustained by nutritious 
food, and the accidents of the disease appropriately met. (See Ascites. ) 
Hemorrhage from the stomach due to cirrhosis of the liver is usually 
uncontrollable by treatment, which should consist in withdrawal of food 
and the administration of opium and styptics (especially Monsel's solu- 
tion), as in hsematemesis from gastric ulcer. (See page 842.) 



DISEASES OF THE LIVER. 



927 



HYPERTROPHIC CIRRHOSIS. 

As has been stated, the liver may become persistently enlarged from 
an increase of its fibrous tissue intimately connected with the bile- ducts, 
but not differing in its histological characteristics from that found in 
atrophic cirrhosis. Hanot and Charcot maintained that this variety of 
cirrhosis originated from the bile-ducts, and it has been asserted that a 
bacterial catarrh of these ducts may be of importance in etiology. 

This affection is of sufficient frequency to be regarded as of clinical 
importance. Jaundice is the most conspicuous symptom. It may be 
either slight or severe, and is likely to be permanent. The absence of 
clay- colored stools indicates that there is no obstruction to the entrance 
of bile into the intestine. The disturbance of digestion is slight, and 
frequently for a long time the nutrition is unaffected. Loss of flesh and 
strength may finally occur, or there may be a rapid rise in temperature 
and an increase in the degree of jaundice, followed by delirium, convul- 
sions, coma, and death in the course of a fortnight. There is no ascites, 
and hemorrhages are infrequent. Persistent enlargement of the liver is 
the chief abnormality, except the jaundice, to be found on physical 
examination, and the anterior border may lie as low as the navel. The 
surface is smooth, the density of the organ is increased, and there is no 
tenderness on palpation. Enlargement of the spleen is present. Hanot 
and Meunier have recently called attention to the presence of a leuko- 
cytosis at various stages of the disease, ranging from twelve thousand 
to twenty-one thousand white corpuscles in the cubic millimetre. Im- 
portance is attached to these observations, since leukocytosis is absent 
in alcoholic cirrhosis and is present to the above extent in cancer alone 
of the various affections of the liver. This condition is regarded as an 
argument in favor of the infectious nature of the disease. 

Diagnosis. — Persistent jaundice, hepatic and splenic enlargement, 
absence of ascites, and gastro-intestinal hemorrhages enable a diagnosis 
of hypertrophic cirrhosis to be made. The enlargement of the liver may 
be simulated by fatty infiltration, amyloid disease, or cancer. The first 
is excluded by the presence of continued jaundice ; the second, not only 
by this evidence, but also by pallor, debility, albuminuria, and dropsy, 
and by a lacking etiology. Time may be necessary for the elimination 
of cancer of the liver, which produces more rapid disturbance of nutri- 
tion and debility and is unlikely to be accompanied by enlargement of 
the spleen. The uncertainty of the diagnosis has led to an exploratory 
laparotomy. The disease has continued for a period of seven years ; and 
it is not known that its progress has ever been prevented or delayed. 

Treatment. — There is no known effective treatment of this disease. 
Symptoms should be met upon general principles ; potassium iodide (one 
grain) and corrosive sublimate (one-sixtieth of a grain) may be given 
continuously, largely to relieve the patient's mind. 



i 



928 



DISEASES OF THE DIGESTIVE APPARATUS. 



AMYLOID LIVER. 

The presence of amyloid material in the liver is connected with the 
destruction of liver-cells, and is productive of corresponding disturbances 
in the function of the liver. Its symptoms are less conspicuous than are 
its physical signs in calling attention to disease of the liver. The imme- 
diate cause of amyloid disease in the liver, as elsewhere, is uncertain. Of 
practical importance from its bearing on diagnosis is its association with 
chronic suppuration, chronic tuberculosis, especially of the lungs, intes- 
tine, kidneys, bones, and joints, and the later stages of syphilis. An 
amyloid liver is sometimes found in cancer, rickets, malaria, gout, leukae- 
mia, pseudo-leukseinia, and chronic nephritis. From the fact that amy- 
loid degeneration usually affects various important organs of the body 
simultaneously, the evidence indicative of this affection of the liver 
depends upon the physical examination of this organ. Pallor, emacia- 
tion, debility, and dropsy are present. There are loss of appetite, belch- 
ing, vomiting, and diarrhoea. The urine is likely to be of low specific 
gravity, pale, with abundant albumin. The liver, although neither pain- 
ful nor tender, may be so enormously enlarged as to produce a sensation of 
fulness and weight, and afford a percussion dulness extending from the 
third rib to the crest of the ilium. The surface is smooth, the density 
increased. The spleen may be enlarged, but from amyloid disease, not 
from obstruction to the passage of its blood into the liver. A diagnosis 
of amyloid liver is probable only when the organ has reached a consider- 
able size, at which time death is likely to occur within the course of a 
few months. It is possible that incipient amyloid degeneration of the 
liver may remain stationary. 

Treatment. — When it can be done, the suppurative or other disease 
which may cause amyloid degeneration of the liver should be removed. 
There is no known remedy which has any direct or indirect influence 
upon the degenerative process itself. 

CANCER OF THE LIVER. 

This term will be employed to designate the malignant tumors of the 
liver in contradistinction to the benignant tumors of this organ. The 
latter are the localized hypertrophy, myxoma, fibroma, lipoma, glioma, 
angioma, benignant adenoma, and retention cysts. The former include 
sarcoma, malignant adenoma, and cancer, to be differentiated only by 
histological examination. 

Etiology. —Cancer of the liver has been found in about three per 
cent, of a large number of cases of death from various causes. It is 
more frequent in women than in men, usually occurring late in middle 
life, but may be found in the earliest years. Heredity, traumatism, and 
gall-stones are generally considered of etiological importance. The more 
common occurrence in women has been in part explained by the greater 
frequency of gall-stones in this sex. 



DISEASES OF THE LIVEE. 



929 



Morbid Anatomy. — Primary and secondary cancer of the liver are 
to be discriminated, the latter being the variety more frequently en- 
countered. Primary cancer presumably arises from the liver- cells and 
from the smaller bile-ducts. Secondary cancer commonly owes its origin 
to primary cancer of the alimentary canal, especially of the stomach, 
rectum, colon, or oesophagus. Cancer of the gall-bladder or of the com- 
mon duct may be primary, or the hepatic cancer may be secondary to 
that of the pancreas, uterus, ovaries, or mammary gland, but more 
commonly it arises in those organs in which the radicles of the portal 
vein begin. 

The growth of the cancer in the liver follows the distribution of 
Glisson's capsule, or is uniformly infiltrated, or is present in the form of 
nodules. These are single or many, even more than one hundred, and 
may vary in size from that of a pin's head upward. The liver, especially 
the right lobe, may attain an enormous size, and the organ has weighed 
as much as twenty-five pounds. As a rule, the more excessive the en- 
largement the greater the loss of liver-cells. The enlargement is likely 
to be symmetrical when Glisson's capsule is conspicuously involved or 
the infiltrating variety is present, and may be exceedingly irregular when 
nodular cancer is the variety concerned. If nodules project above the 
surface they are rounded or flattened, and often umbilicated from central 
fatty degeneration and absorption. The larger masses are frequently 
surrounded by smaller growths in close proximity and tending to be- 
come fused with the former. The section of the liver varies in appear- 
ance according to the method of invasion of the cancer, the extent it 
has reached, the degenerations it has undergone, and the disturbances 
it has produced in the blood-vessels and bile-ducts. The infiltrating 
forms of cancer, whether in Glisson's capsule or spreading diffusely, may 
follow closely the structural details of the normal liver, and the appear- 
ances may resemble those of fibrous hepatitis. The nodules are usually 
rounded, more gray or white when small, more red or yellow when large, 
but are sometimes of a translucent gray (hyaline or colloid) appearance. 
The red color is due to injection or hemorrhage, the yellow color to fat 
or necrosis. The dark gray or black color indicates a melanotic cancer 
or sarcoma. The consistency of the nodules is soft (medullary or enceph- 
aloid) or hard (fibrous or scirrhous). Finally, cavities containing a thin, 
yellow fluid may be present within the nodule as a result of softening. 

The blood-vessels of the liver may be obstructed or obliterated by the 
compression of the cancerous growths, which may also perforate their 
walls and grow along their interior. Obstruction results to the flow of 
blood through the corresponding parts of the liver, which become en- 
gorged with blood, and perhaps necrotic. Compression of the bile-ducts 
by the nodules produces dilatation and jaundice, either limited to por- 
tions of the liver or affecting the various tissues of the body, according 
to the seat of the obstruction. 

59 



930 



DISEASES OF THE DIGESTIVE APPARATUS. 



Extension of the disease to the lymph-glands in the portal fissure, with 
possible obliteration of the portal vein, obstruction of the common bile- 
duct, or perforation of the gall-bladder, may occur. The peritoneum, 
especially of the omentum, and Douglas's fossa, is likely to be invaded, 
and the disease may extend to the spleen, pancreas, and kidneys, and to 
the lungs. 

Symptoms. — The disturbances associated with cancer of the liver, as 
a rule, are complicated with those due to cancer of the organ in which 
the disease is primary. The symptoms attributable to the affection of 
the liver are usually dependent upon the extent of the disease in this 
organ, and, for practical reasons, no distinction is drawn between the 
results of primary and those of secondary disease of the liver. Loss of 
appetite, nausea, vomiting, and constipation are usually present, but do 
not indicate necessarily that the liver is diseased. Emaciation and de- 
bility eventually occur, sometimes with great rapidity. Disease of the 
liver is more directly suggested by pain and jaundice. The former, 
varying in degree, is almost constant, and may be limited to the right 
hypochondrium, or radiate in all directions from this region. Jaundice 
is present in at least half the cases, varies in degree, and is sometimes 
extreme. The abdomen becomes distended with fluid in about as many 
cases. The fluid is either due to obstruction to the flow of blood through 
the portal vein or is the result of cancerous peritonitis. Cutaneous 
oedema is likely to appear towards the end of life. Hemorrhages in the 
skin, or from the nose, stomach, and bowels, at times take place, and itch- 
ing and hiccough may be troublesome. The pulse becomes weak, and is 
slow when jaundice is present. The temperature is usually normal, but 
is likely to be febrile if the disease runs a rapid course associated with 
suppuration, and the fever may be continuous or intermittent. A leuko- 
cytosis even to the extent of forty thousand leukocytes in the cubic 
millimetre may be present. The urine is diminished in quantity, high- 
colored, frequently with a trace of albumin, and bile-pigment may be 
present even when there is no discoloration of the skin. Indican is in- 
creased, and melanin or melanogen may be present in melanotic cancer or 
sarcoma. The presence of melanin is indicated by a dark, almost black, 
color of the urine when passed, whereas melanogen is made evident by 
the urine becoming black after a time or when heated with nitric acid. 
The faeces may or may not be clay- colored, even when jaundice is present. 
The liver is usually, sometimes visibly, enlarged, and the area of hepatic 
dulness may extend from the third rib to the crest of the ilium. The 
edge of the liver is generally readily felt, and cancerous nodules, if 
present, may be palpated and sometimes seen through the abdominal 
wall. At times they are so soft in consistency as to suggest the presence 
of fluid. The enlarged liver descends with the diaphragm, and the left 
lobe may so transmit the aortic impulse as to simulate aneurism. The 
spleen, as a rule, is not enlarged. 



DISEASES OF THE GALL-BLADDER AND BILE-DUCTS. 931 

Diagnosis.— Cancer of the liver is to be diagnosticated by progressive 
loss of flesh and strength, pain and tenderness in the right hypochon- 
drium, and enlargement, especially nodular, of the liver. The presence of 
leukocytosis, jaundice, ascites, and peritoneal nodules, the last apparent 
perhaps only on rectal examination, offers additional favorable evidence. 
The enlarged nodular liver produced by an echinococcus is not accom- 
panied with the cachexia of cancer, and exploratory puncture of the 
nodule reveals a clear fluid, but not blood. Other nodular enlargements 
of the liver from hyperplasia or fibrous hepatitis lack the cachexia 
of cancer, and are of slower growth. If the liver is symmetrically en- 
larged, hypertrophic cirrhosis might be excluded by the failing splenic 
enlargement and the long period of jaundice without emaciation and 
debility. Amyloid enlargement of the liver is slower in progress, 
jaundice is infrequent, albuminuria and dropsy are more constant and 
severe, and the etiology may be apparent. If the liver is not enlarged, 
and the symptoms are suggestive of cancer, it may be impossible to 
discriminate between cancer of neighboring organs and that of the liver, 
especially if the former are adherent to the liver. 

Prognosis. — Cancer of the liver is universally fatal, usually within a 
year after its recognition. The disease may progress so rapidly, with 
loss of flesh and strength, that death takes place in the course of a few 
weeks, perhaps from cancerous peritonitis, or suddenly from intraperi- 
toneal hemorrhage from the rupture of a vascular nodule. If the dura- 
tion of the disease extends over a longer period, it is likely to terminate 
fatally by progressive weakness, with eventual pulmonary oedema. 

Treatment. — The only treatment of cancer of the liver is palliative. 

DISEASES OF THE GALL-BLADDER AND BILE-DUCTS. 

Under this term are to be considered the pathological processes in- 
volving the gall-bladder and bile-ducts, which, although they are often 
simultaneously affected, may be independently diseased. 

JAUNDICE. ICTERUS. 

Definition. — A pathological yellow discoloration of the skin and 
many of the tissues and fluids of the body, usually, if not invariably, 
due to bile-pigment, and occurring in many diseases and under a variety 
of conditions. 

Etiology. — Mainly through the researches of Stadelmann it is now 
generally admitted that all cases of jaundice are due to the obstruction 
of the outflow of bile from the liver and the absorption of its pigment 
through the lymphatics of the liver, for there is no absorption of bile 
when the common bile-duct and the thoracic duct are tied. The as- 
sumption of a hematogenous jaundice in which the pigment is supposed 
to be set free in the blood without the mediation of the liver lacks sup- 



932 



DISEASES OF THE DIGESTIVE APPARATUS. 



port, since it is shown that the agents which set free the haemoglobin 
also produce obstruction of the small intra-hepatic bile- ducts, thus favor- 
ing the absorption of bile, and the presence of bile-acids in the urine in 
such cases shows that absorption of bile has taken place. The idea of 
a jaundice from the suppression of the secretion of bile is effectually 
disposed of, especially by the experiments of Stein, which show that 
jaundice does not occur in birds and vertebrates from whom the liver 
has been removed. 

Obstruction to the outflow of bile being the immediate cause of 
jaundice, it is convenient to consider that such obstruction may affect 
the common and hepatic bile-ducts or the intra-hepatic bile-ducts. 
Obstruction of the former may be produced by external causes, as con- 
striction from scars or compression from tumors, whether neoplastic, 
aneurismal, parasitic (echinococcus), or faecal. The internal causes 
producing obstruction are inflammation, stricture, tumors, or foreign 
bodies. 

The external causes of obstruction of the intra-hepatic ducts are the 
various inflammations of the liver and the tumors and parasites of this 
organ. Passive congestion and fatty infiltration may be added. The in- 
ternal causes are catarrhal and suppurative inflammation, calculi, con- 
cretions, and inspissated bile. 

Morbid Anatomy. — The skin may be of a pale yellow or deep yel- 
lowish-brown color, suggesting that of bronze, and shades of green and 
blue may be present. The darker colors represent a more prolonged and 
more complete obstruction. The variation in color is likewise dependent 
upon the quantity of normal pigment, the thickness of the epidermis, and 
the quantity and quality of the blood in the part stained. The teeth, 
cartilage, nerve-tissue, tears, saliva, and mucus are not discolored. The 
other tissues and fluids of the body, especially the urine, sweat, and 
milk, contain bile-pigment. The fibrinous sputa of acute pneumonia and 
acute inflammatory exudations are pigmented. The liver and kidneys 
may present a dark olive-green color, and their cells be diffusely stained 
or contain pigmented granules or scales. The latter may be present in 
the canal of the tubules. If the obstruction lies at the duodenal end 
of the common duct, where it is most frequently found, as a thickened 
mucous membrane or a plug of mucus due to catarrh, the bile- ducts 
are distended with dark viscid bile, and, if the obstruction is of a more 
permanent character, as a tumor or stricture, the ducts are dilated as 
well. If the larger bile-ducts are unobstructed, a microscopic examina- 
tion of the liver may show elongated and branching plugs of inspissated 
bile within capillary bile- ducts. ^Yhen the larger bile-ducts are inflamed, 
their walls are likely to be thickened and ulcerated and their contents a 
thin, gruel-like fluid. 

Symptoms. — The disturbances from obstruction to the passage of bile 
into the duodenum depend upon the absorption of bile-pigment and bile- 



DISEASES OF THE GAEL- BLADDER AND BILE-DUCTS. 933 

acids and the absence of bile from the intestinal contents. Within three 
or four days after the obstruction has taken place — and the earlier the 
more sudden and complete the obstruction — the skin and visible mucous 
membranes become yellow. This color is usually first observed in the 
conjunctivae, which are strongly contrasted with the white sclerotic coat. 

Discoloration of the urine may be noticed even earlier than that 
of the skin, and as it increases in intensity assumes a dark brown re- 
sembling that of porter. The urine readily foams when shaken, and the 
froth has a yellow color. The quantity, reaction, and specific gravity are 
normal, and there is neither albumin nor sugar. On microscopical ex- 
amination hyaline casts are often found, and the detached epithelium of 
the urinary tract is stained yellow. The urine may be similarly discolored 
after the use of rhubarb, senna., and santonin ; but then it does not foam 
when shaken, and the color becomes red when caustic potash is added. 
The detection of bilirubin in the urine offers positive evidence of the 
presence of bile-pigment. This is usually accomplished by the use of 
Gmelin's test, which may lack a positive result in stale urine or in that 
of a patient with fever. An equal quantity of ordinary nitric acid is 
allowed to flow down the side of a wineglass containing a few drachms 
of urine, or a few drops of separated urine and acid are caused to unite 
in a thin layer on a white dish. Eosenbach filters the urine, and applies 
a drop of the acid to the surface of the stained filter-paper. If bilirubin 
is present it is oxidized when it comes in contact with the acid, with 
a resulting play of colors from green through blue, violet, and red to 
yellow, in which the presence of green is characteristic. A very con- 
venient and easily applied test is that of Marechal as modified by Eosin. 
Tincture of iodine is diluted with ten parts of alcohol. A thin layer of 
this diluted tincture is allowed to flow along the side of the wineglass 
upon the surface of the contained urine, which may be diluted if deeply 
pigmented. The presence of bilirubin is shown by the formation of a 
green ring at the line of apposition of the two fluids. The search for bile- 
acids is rendered unnecessary as a means of recognizing the especial 
variety of jaundice, since it is probable that all jaundice is of obstructive 
origin, and it has been found that bile-acids may be present in the urine 
of healthy persons. They may be rapidly decomposed in the blood, 
perhaps occurring only in traces in the urine. The search for them is 
laborious and without practical value. They are usually found by 
Pettenkofer's test as modified by Strassburger. 

The effect of the bile-acids is especially manifested on the nervous 
system. Headache and dizziness are frequent. The patient is often 
irritable, despondent, dull and stupid, or restless and wakeful. Vision 
may become less distinct as darkness approaches, hemcralopia, or it may 
then become stronger, nyctalopia. Xanthopsia, the yellow appearance of 
objects, is of rare occurrence, aud hence is not to be attributed to bile- 
pigment. 



934 



DISEASES OP THE DIGESTIVE APPARATUS. 



The absence of bile from the intestines interferes with the absorption 
of fat 7 favors putrefaction, and causes the faeces to become clay -colored. 
The unabsorbed fat crystallizes into acicular clusters which are to be 
found in the faeces, and are chemically, according to Oesterlen, a magnesian 
soap. The increased putrefaction o£ the intestinal contents is indicated 
by flatulence and the extremely offensive odor of the escaping gas. The 
formation of the latter may become so abundant as to cause tympany, 
colic, and constipation. The stools become clay-colored, since they are 
deprived of urobilin, their normal coloring matter, which arises from the 
transformation in the intestine of bilirubin. It is to be remembered that 
the faeces may be pale from a milk diet when there is no obstruction to 
the entrance of bile, and dark-colored from the presence of iron or bis- 
muth even when bile is absent. 

A bitter or disagreeable taste in the mouth, loss of appetite, nausea, 
a faint, "all gone" feeling before and a sensation of epigastric pressure 
after eating, are often present, and usually p recede the occurrence of 
the jaundice. The tongue may be coated, the breath fetid, the area of 
hepatic dulness increased, the gall-bladder distended, and both liver 
and gall-bladder tender and painful. 

Itching of the skin, one of the most distressing symptoms of jaundice, 
as a rule, eventually occurs, and is due either to bile-pigment in the 
skin or to the absorption of bile-acids. It is most severe in the palms 
and soles and between the fingers and toes, but may be found every- 
where, and is especially disagreeable at night and when the patient is in 
bed. In consequence of scratching, papules, pustules, ulcers, and crusts 
are formed. Boils and carbuncles may occur, and urticaria, herpes, and 
xanthelasma may appear. Cutaneous as well as internal hemorrhages 
are frequent. A slow pulse is the rule, due, according to Legg, to the 
effect of bile-acids on the cardiac ganglia. The beat may be twenty per 
minute, but usually ranges between forty and sixty. Bespiration and 
temperature are normal in the absence of complicating inflammations. 
The occurrence of fever in cases of jaundice is characterized by a lower 
temperature and slower pulse than are present in fever without jaundice. 

Diagnosis. — The discoloration of the skin and urine and the presence 
of bile-pigment in the latter establish the diagnosis of jaundice. The 
mere discoloration of the skin is insufficient for this purpose, since it may 
be simulated in the colored races and in Addison's disease, and if the 
jaundiced patient is first seen with artificial light the yellow color may 
be invisible. In Addison's disease the sclerotic is white, the pigment 
is most abundant in the head, hands, and flexures of the body, and the 
discoloration has existed for a long time. 

In determining the seat of the obstruction the examination of the faeces 
and gall-bladder is of especial importance. The paler the faeces, and the 
more acute and intense the jaundice, the more likely are the extra-hepatic 
ducts to be obstructed. If the obstruction is near the duodenum, the 



DISEASES OF THE GALL-BLADDER AND BILE-DUCTS. 935 

faeces are colorless and the gall-bladder may be distended. If the hepatic 
duct is obstructed, although the feeces are colorless, the gall-bladder is 
not distended. The concurrence of jaundice and bile-stained fseces in- 
dicates an incomplete obstruction of the extra-hepatic bile- ducts, or that 
the cause of the obstruction lies within the liver. Persistence of the 
jaundice, with the absence of pain and acute symptoms, would favor the 
latter seat of the obstruction. 

The duration of the jaundice is of importance in the diagnosis of the 
cause. Acute jaundice lasts several weeks ; chronic jaundice extends 
over several months or years. Acute jaundice, if without complication, 
is probably catarrhal, but if associated with prolonged fever the catarrh 
has probably affected the smaller bile- ducts. If accompanied by attacks 
of pain in the region of the gall-bladder or by biliary colic, the jaun- 
dice is probably due to gall-stones. Chronic jaundice without conspicuous 
pain is likely to be due to fibrous hepatitis, to cancer of the liver, or to 
chronic passive congestion of this organ ; ascites with enlarged spleen 
or symmetrical enlargement of the liver suggests the first, enlargement 
of the liver with deformity the second, and evident mitral stenosis the 
third of these conditions. 

Prognosis. — Acute catarrhal jaundice usually terminates favorably 
within the course of six weeks, yet fatal acute yellow atrophy of the liver 
may be preceded by a fortnight of apparently simple catarrhal jaundice. 
Acute jaundice from gall-stones, as a rule, rapidly subsides with the 
cessation of the attack of biliary colic. The prognosis of acute febrile 
jaundice is uncertain during the persistence of the fever, in consequence 
of the gravity of the complications which may arise. Chronic jaundice, 
especially when increasing in intensity, is of serious if not of grave 
importance, particularly if without fever and pain ; then persistence with 
cachexia is suggestive of malignant disease of the liver ; if the persistence 
is without cachexia, hypertrophic cirrhosis is probable. 

Treatment. — As jaundice is only a symptom, its radical treatment is 
that of the disease which produces it. The various treatments of these 
diseases will be found under their respective headings ; that of catarrhal 
jaundice is given in the article on inflammation of the gall-ducts. (See 
page 938.) When in any case it is not possible to determine the cause of 
a jaundice, a moderate careful treatment in accordance with the principles 
enunciated in the articles on catarrhal jaundice and on chronic hepatic 
congestion should be carried out. 

INFLAMMATION OF THE GALL-DUCTS, CHOLANGITIS, AND OF THE 
GALL-BLADDER, CHOLECYSTITIS. 

Etiology. — Inflammation of the bile-ducts and gall-bladder usually 
results from the continuous extension of a catarrh of the duodenum 
along the common duct into the hepatic and cystic ducts and into the 
gall-bladder. Duodenal catarrh is generally continued from the stomach, 



936 



DISEASES OF THE DIGESTIVE APPARATUS. 



where it is most frequently caused by the presence of some irritant, as 
food, drink, medicine, or poison. The persistence and severity of the 
catarrh of the bile- ducts and gall-bladder largely depend upon the pres- 
ence in them of some mechanical or microbial irritant, as gall-stones, 
verminous parasites, or bacteria. Inflammation of the biliary tract may 
also occur in the course of infectious diseases, as pneumonia, typhoid 
fever, malaria, and erysipelas, and the reported epidemics of simple 
catarrhal jaundice are presumably due to the action of some unknown 
infectious agent upon the gall-ducts. It is a frequent accompaniment of 
passive congestion, acute and chronic inflammation, and cancer, of the 
liver. 

Morbid Anatomy. — The inflammation is most frequently limited to 
the intestinal end of the common bile-duct (choledochitis), but it may be 
continued along this duct to the hepatic ducts and into the liver, or 
through the cystic duct into the gall-bladder. On the contrary, the in- 
flammation may be limited to the cystic duct or to the gall-bladder, or may 
occur simultaneously in both. The anatomical varieties of inflammation 
of especial importance are the catarrhal and the suppurative. Catarrhal 
choledochitis, the most frequent cause of acute jaundice, is manifested by 
swelling and injection of the mucous membrane of the intestinal part of 
the duct, the outlet of which is filled with an opaque, viscid material 
containing abundant epithelial cells. Nearer the liver the mucous mem- 
brane of the duct may show little or no alteration, or appearances may 
be found similar to those just mentioned. Catarrhal inflammation of the 
cystic duct and of the gall-bladder is characterized by similar appear- 
ances. If the cystic duct becomes obstructed, dilatation of the gall- 
bladder results, and the latter tends to assume a pear shape, sometimes 
containing a quart or more of pale, watery, or slimy fluid. The mucous 
membrane becomes thin, smooth, and shining. This condition is called 
dropsy of the gall-bladder. If the obstruction persists, the gall-bladder 
shrinks very greatly, and its walls are thickened and calcified. 

In suppurative inflammation of the biliary tract the mucous membrane 
is thickened, injected, and contains hemorrhages. In severe cases it may 
be ulcerated or necrotic and patches of fibrinous exudation niay be pres- 
ent. Pus or muco-pus, but little stained with bile, is found in the dilated 
ducts, even in the intra-hepatic branches. When the dilated gall-bladder 
is filled with a purulent fluid the term empyema of the gall-bladder is 
applied. The extension of a suppurative cholangitis to the intra-hepatic 
branches of the bile- ducts tends to produce multiple, disseminated, small 
abscesses of the liver. If these coalesce, larger abscesses are formed, 
and, when superficial, more or less extensive localized peritonitis pur- 
suing the course of a suppurative perihepatitis occurs over them. Sup- 
purative inflammation of the gall-bladder and extra-hepatic ducts may 
extend to surrounding parts, frequently producing a localized peritonitis, 
and sometimes causing inflammation of the portal vein. Perforation 



DISEASES OF THE GALL- BLADDER AND BILE-DUCTS. 



937 



may occur, resulting in the establishment of fistulous communications 
between the biliary and the alimentary, respiratory, or urinary tract, 
or the abscess may be evacuated through the abdominal wall. 

The severer forms of inflammation may result in the production of 
cicatricial tissue, the contraction of which at times produces narrowing 
and distortion of the biliary tract and obstruction of the portal vein. 

Symptoms. — Inflammation of the bile-ducts, perhaps extended to the 
gall-bladder, is first made evident by the occurrence of jaundice, usually 
slight at the outset, but rapidly increasing in intensity. This symptom 
is the well-known catarrhal jaundice. For several days a period of 
malaise or some of the symptoms of gastro- duodenal catarrh, as failing 
appetite, nausea or vomiting, belching, epigastric discomfort, and irreg- 
ular stools, are likely to precede the occurrence of the jaundice. The 
temperature is but little elevated. The liver is slightly enlarged and 
somewhat sensitive, and the patient presents the general and local dis- 
turbances considered in detail in the section on jaundice. 

Catarrhal cholangitis may extend into the minutest gall -ducts of the 
liver and become persistent. The extra-hepatic ducts then show no 
alteration. The important symptom is continuous jaundice, and the 
course of this affection is that of hypertrophic cirrhosis. 

When catarrhal inflammation of the gall-bladder exists independently 
of catarrh of the common bile-duct, it is usually associated with obstruc- 
tion of the cystic duct ; jaundice is not likely to occur j pain and tender- 
ness in the region of the gall-bladder are present. The pain may be 
sudden and severe, associated with vomiting, and in the course of twenty- 
four hours the progress of the disease has so simulated acute intestinal 
obstruction as to lead to a laparotomy. Physical examination in the 
sensitive region discloses the presence of a tender, more or less rounded 
and elongated, elastic tumor, dull on percussion, intimately connected with 
the liver, and changing position with the movements of the diaphragm. 
Exceptionally, as mentioned by Eichhorst, an overlying coil of intestine 
may lie between the liver and the distended gall-bladder. 

Suppurative cholangitis and cholecystitis are usually preceded by the 
milder symptoms of catarrhal inflammation. The change in its character 
is indicated by chills and fever. The former, usually irregular, are 
sometimes suggestive of malaria. The range of temperature is like that 
described in connection with abscess of the liver, and may persist for 
months. The disease becomes a septicaemia, and its course is modified 
as the resulting abscesses remain confined or find an outlet through a 
hollow organ or the skin or into the peritoneal cavity. 

Diagnosis. — The determination of a catarrhal jaundice establishes 
the diagnosis of catarrh of the common bile-duct. The extension of 
the inflammation towards the liver is rendered probable by increasing 
severity of the symptoms, especially by a higher range of temperature. 
Continuance of the jaundice after the disappearance of the acute dis- 



938 



DISEASES OE THE DIGESTIVE APPARATUS. 



turbances and the relief of the obstruction at the duodenal end of the 
duct suggests that the intra-hepatic bile-ducts are affected, and the 
diagnosis eventually to be made is likely to be that of hypertrophic 
cirrhosis. Catarrhal cholecystitis alone, if persistent, forms an abdom- 
inal tumor which may become so large as to be confounded with a 
pelvic tumor. The history of the case, the seat of the early pain, and 
the bimanual examination of the pelvic contents will suffice to exclude 
a pelvic tumor. A movable kidney is more deeply seated, is less tender, 
is more readily displaced, and can be pushed into place. The enlarged 
gall-bladder may be mistaken for cancer of the liver. The latter is to be 
excluded by the frequent deformity of the liver and the usual prolonged 
cachexia and frequent jaundice. An echinococcus cyst in the region 
of the gall-bladder is rather spherical than pear-shaped, although the 
aspirator may be needed to discriminate between the two. Suppurative 
cholangitis or cholecystitis is to be diagnosticated when the chills and 
higher range of temperature, the general symptoms of septicaemia, and 
the local indications of peritonitis or abscess of the liver appear. 

Prognosis. — Catarrhal choledochitis, simple catarrhal jaundice, usu- 
ally causes but little disturbance, and runs its course in a few weeks, 
jaundice being the last symptom to disappear. The longer the persist- 
ence of the latter, the more likely the occurrence of permanent and irre- 
mediable changes in the liver resulting in hypertrophic cirrhosis. 

The immediate attack of catarrhal cholecystitis is likely to end favor- 
ably. The disease tends to recur, however. If cystic dropsy of the gall- 
bladder occurs, an abdominal tumor is formed which usually proves 
harmless. Suppurative inflammation of the biliary tract is always a 
serious affection, from the tendency it has to cause peritonitis, abscess 
of the liver, and pylephlebitis. 

Treatment. — In catarrh of the bile-ducts and the catarrhal jaundice 
to which it gives rise it is rarely necessary or advisable to put the patient 
to bed, though of course violent exercise must be avoided. In many 
cases there is a coincident gastric or duodenal catarrh. Moreover, the 
digestive powers are distinctly impaired by the absence of bile. The diet 
should therefore always be light, though nutritious. Further, sweets, 
fatty matters, and starchy foods, which are more or less contra-indicated 
by gastro -intestinal catarrh, are especially to be forbidden in catarrhal 
jaundice, because the products of their fermentation (especially liable to 
occur in the intestines when bile is not present) are irritant to the liver. 

As an excess of nitrogenous food is also very capable of doing injury 
in catarrhal jaundice, and as the digestive power is often so weakened 
that spinach and other green vegetables cannot be readily assimilated, it 
is evident that great care is necessary in feeding the patient. In many 
cases a diet of skimmed milk, or, if the patient prefer it, of buttermilk, 
koumiss, matzoon, or some similar preparation of milk, may be rigidly 
enforced. When meats are allowed they should be very light in char- 



DISEASES OF THE GALL- BLADDER AND BILE-DUCTS. 939 

acter, and the quantity as well as the quality of food should be carefully 
restricted. 

In the beginning of an attack of biliary catarrh an attempt should be 
made by the free use of calomel, followed by salines, to remove the exist- 
ing hepatic congestion ; this in many cases may be followed or accom- 
panied by the administration of silver nitrate, for the purpose of affecting 
the gastric and duodenal mucous membrane. Both mercurials and alka- 
lies are especially indicated, from the fact that they not only have a 
tendency to increase the biliary secretion and to make it more fluid, 
but also are antiphlogistics, with a pronounced tendency to render less 
adhesive the mucous secretions from the biliary ducts. An ounce of 
potassium citrate may be given daily for a short time, or thirty grains of 
sodium bicarbonate with twenty grains of potassium bicarbonate may 
be exhibited every two hours in dilute solution. Mild counter-irritation 
is sometimes of service, but should be preferably made by nitrohydro- 
chloric acid. (See page 914.) 

Suppurative inflammation of the gall- duds is not amenable to treatment : 
it usually gives rise to multiple abscesses of the liver of pyeemic nature. 
The best that can be done is to meet symptoms as they arise, and to 
evacuate any local collections of pus that may present themselves. 

CHOLELITHIASIS. 

Definition. — The disturbances produced by gall-stones. 

Etiology. — Gall-stones occur in about seven per cent, of all autop- 
sies, and are usually found in elderly adults, but sometimes in early 
childhood. Although present after death, according to Schroder, in 
twenty-five per cent, of all persons above sixty years of age, the dis- 
turbances resulting from them are more frequent between the ages of 
thirty and fifty. The gall-stones are formed within the hepatic ducts 
and in the gall-bladder, and are chiefly composed of cholesterin, bile- 
pigment, and lime, which are generally considered to be precipitated 
from the bile. Naunyn maintains that the cholesterin is formed from 
the fattily degenerated epithelium of the biliary tract, and that stag- 
nation of the bile favors the formation of the calculus. Catarrh of the 
bile-ducts is also of probable importance as favoring the degeneration 
of epithelium and precipitation from the bile. Of late the frequent 
association of bacteria with gall-stones has suggested that the former 
may be of etiological importance. Gall-stones are found three or four 
times as often in women as in men, and especially in women who have 
borne children or from whom •abdominal tumors have been removed. 
In more than half of a considerable number of cases of gall-stones in 
women there was likewise a corset liver, and movable kidney and liver, 
also of etiological importance, are more frequent in females. Nutmeg 
liver, adhesions of the gall-bladder, and fibrous degeneration of its wall 
may aid in the formation of gall-stones by preventing the passage of 



940 



DISEASES OF THE DIGESTIVE APPARATUS. 



bile. Persons of sedentary habits, and rather the fat than the lean, are 
more prone to gall-stones. According to Musser, gall-stones are present 
in sixty-nine per cent, of cases of primary cancer of the gall-bladder, an 
affection likely to be accompanied by catarrhal inflammation and bili- 
ary stagnation. Foreign bodies, clotted blood, seeds, parasites, bacteria, 
mercury, and a needle have been found in the centre of a gall-stone. 

MORBID Ahatomy. — Single or many gall-stones are to be found in the 
biliary tract, and when they are exceedingly minute the gall-bladder may 
contain enormous numbers. They vary in size from that of a pin' s head 
upward, and may become as large as a hen's egg. They are round, ovoid, 
or elongated, and when multiple are likely to be faceted. The facets are 
usually regarded as the result of pressure, but may be present when the 
calculi do not fill the gall-bladder. According to Orth, the facets result 
from the deposition of the constituents of the gall-stone on those surfaces 
which do not lie in contact. The apposed surfaces of elongated calculi 
may be hollowed and rounded like the ends of bones in joints. Gall- 
stones vary in color from the white or yellowish- white of cholesterin to the 
dark chocolate color of pigment-lime. The calculus on section may appear 
homogeneous or have a deeply pigmented nucleus. Some calculi are 
formed almost entirely of cholesterin, which is dissolved by alcoholized 
ether, on the evaporation of which crystals of cholesterin appear. Pig- 
ment-lime, as a rule bilirubin and lime, is usually present in greater or 
less quantity, and is sometimes the chief constituent of the calculus. 
The addition of a dilute solution of potash to washed fragments of the 
calculus produces a deep yellow color, forming prismatic rings when 
treated with impure nitric acid. Usually both cholesterin and pigment- 
lime are present. Traces of iron and copper at times may be found. 
The cholesterin calculi are firm, white, crystalline, cutting like wax ; 
pigment-lime calculi are dark in color, homogeneous, and brittle. 

Although gall-stones are most frequently found in the gall-bladder, 
they are to be seen at any part of the biliary tract. They may lie in a 
dilated canal, which may be tortuous and bent, or be present in one 
which has a lateral dilatation or diverticulum The mucous mem- 
brane either shows no alterations, or presents the characteristics of 
mild or severe inflammation. The resulting disturbances appear to be 
largely dependent upon the association of bacteria, which are always 
present at the duodenal end of the common duct. Dilatation of the gall- 
ducts and stagnation of the bile favor the extension of the bacteria 
towards the liver, and, although normal bile is free from bacteria, the 
latter may grow in dilute bile. The typhoid and the colon bacillus, 
Friedlander's bacillus, the staphylococcus, streptococcus, and pneumo- 
coccus, have been found in the inflammatory products associated with 
gall-stones. The inflammation may extend to adjacent parts, as the 
peritoneum or the connective tissue of the portal fissure, with the pro- 
duction of adhesions and abscesses, and the eventual establishment of 



DISEASES OF THE GALL-BLADDER AND BILE-DUCTS. 941 

an opening between the biliary tract and the stomach, duodenum, trans- 
verse colon, pelvis of the right kidney, ureter, abdominal wall, or 
bronchi, and the gall-stones may escape from the body through such 
openings. The suppurative inflammation may be continued into the 
liver, either directly by means of the bile-ducts or indirectly by the pro- 
duction of pylephlebitis, thus producing abscesses, although Dabney has 
shown that less than ten per cent, of the abscesses of the liver are attrib- 
utable to gall-stones. When chronic inflammation of the biliary tract 
results from the presence of gall-stones, scars, fibrous adhesions within 
and outside of the ducts and gall-bladder, thickenings, indurations, 
twists, cysts, diverticula, or fibrous hepatitis may result. 

Symptoms. — Gall-stones are often present, and, when small, may even 
pass through the common bile-duct without giving rise to symptoms. 
Since the calculi, however, vary in size and are often numerous, the 
symptoms due to their passage may frequently recur within a short 
time, or months or years of freedom may ensue, to be ended by fresh 
paroxysms. The disturbances which are due to gall-stones are, first, 
those resulting from the expulsion, impaction, or incarceration of the 
stone, and, second, those dependent upon subsequent inflammatory con- 
ditions. The patient who suffers from the severe symptoms of gall- 
stones may have had antecedent digestive disturbances, slight jaundice, 
or sensitiveness in the region of the liver, the so-called bilious attacks, 
The symptom which usually first suggests the presence of the gall-stone 
is biliary colic, which, however, is no absolute sign of an attempt at the 
expulsion of the gall-stone, since it may be the result of an inflamed gall- 
bladder, or be recurrent and no gall-stone be present, and there may be 
no colic when gall-stones large enough to produce intestinal obstruction 
have escaped into the bowel. 

Biliary colic, according to Kraus, oftenest takes place two or three 
hours after eating, especially at night, and is perhaps excited by unsuit- 
able food or drink. The pain is usually sudden and severe, and rapidly 
increases in intensity. It is generally referred to a limited region to the 
right of the median line a short distance below the ensiform cartilage, 
or to the vicinity of the gall-bladder, and may radiate in various direc- 
tions ; at times it is referred to the right shoulder and arm. It is 
cutting, stabbing, tearing, or twisting, and is not relieved by pressure. 
It may suddenly cease, or it may last for hours, days, or weeks, with 
occasional intervals of freedom. When the pain is especially severe the 
patient is restless and has an anxious expression, the skin is cold and 
moist, perhaps cyanotic, and hiccough may be present. Vomiting soon 
follows, at first of the contents of the stomach, then of bile, if the 
common duct is not obstructed, and, rarely, of gall-stones. As a rule, 
after the contents of the stomach have been expelled repeated retching 
follows. 

The attack of colic is in more than one-half of the cases followed in 



.942 



DISEASES OF THE DIGESTIVE APPARATUS. 



the course of a few hours by chills or rigors and an elevated temperature. 
The temperature may be as high as 104° or 105° F., and the fever usually 
quickly subsides with the cessation of the colic, but is of long duration if 
inflammation of the biliary tract ensues. It may be continuous, remit- 
tent, or intermittent, in the latter case resembling malaria, and then to 
be regarded as a septic fever the result of an infection of the patient. 
The pulse is often slow, but it may be frequent, weak, and irregular. 

Jaundice is present in about one-half of the cases, beginning within a 
few hours after the attack of pain. Although probably an obstructive 
jaundice, it does not necessarily indicate that the gall-stone lies in the 
common duct, since it may be present when the gall-stones are in the 
gall-bladder. Unless inflammation of the biliary tract ensues or the gall- 
stones become impacted or incarcerated, jaundice usually disappears in 
the course of a week or two after the attack of pain. When the common 
duct is obstructed, either by the calculus or by swelling of the mucous 
membrane, the bowels are constipated and the stools are colorless and 
offensive. They may be alternately colored and without color when the 
duodenal opening of the common duct is only temporarily Closed. 

The abdomen is not distended. The painful region is usually sensi- 
tive, and palpation is resisted by the tense rectus muscle. The liver is 
likely to be somewhat enlarged, and the anterior edge may be found on a 
level with the navel. The swelling of the liver, like the jaundice, soon 
subsides with the disappearance of the colic, but may persist and increase 
with the evidence of inflammation of the biliary tract. The region of 
the gall-bladder may be tender, and this organ is palpable in one-third 
of the cases, but it may be contracted and inappreciable. Crepitation of 
the distended gall-bladder has been observed when the gall-bladder con- 
tained many small calculi, and a friction-sound has been heard over its 
inflamed surface. Persistent pain and tenderness in the region of the 
gall-bladder after disappearance of the colic are suggestive of the occur- 
rence of inflammation. 

The spleen may be found enlarged, though its swelling is slight and 
inconstant unless prolonged inflammation of the biliary tract occurs. 

The attempt at the expulsion of the stone may be successful, with a 
speedy disappearance of all the symptoms and the elimination of the 
calculus. The latter, as a rule, is possible only in the case of stones not 
larger than peas. The attempt may be unsuccessful, the calculus remain- 
ing, although the symptoms disappear. The retained gall-stones are 
either incarcerated or impacted. If incarcerated in the gall-bladder they 
may produce no further disturbance, or renewed attempts at expulsion 
take place, or inflammation of the gall-bladder, perhaps infectious, oc- 
curs, or the gall-bladder becomes contracted, forming a capsule, perhaps 
calcified, around the gall-stone. If incarcerated in the common duct, 
renewed efforts at expulsion are frequent, resembling those already de- 
scribed, ceasing only with the passage of the stone or with the death of 



DISEASES OF THE GALL-BLADDER AND BILE-DUCTS. 943 

the patient, which may be directly attributable to the presence of the 
calculus, as from abscess of the liver, chronic hepatitis, or peritonitis. 

If the gall-stone is impacted in the cystic duct, the immediate result 
is a painful distention of the gall-bladder, due to retention of secretion, 
unless a complicating infection gives rise to the presence of pus. If the 
stone is impacted in the common duct, the pain eventually ceases or be- 
comes slight, jaundice persists and increases, the bile-ducts continue to 
dilate, and the gall-stone is either expelled or is encapsulated in a cir- 
cumscribed lateral dilatation, a diverticulum. The passage of bile then 
normally takes place, the jaundice disappears, and the patient recovers 
health and strength. If the impacted calculus is neither exiDelled nor 
incarcerated, jaundice persists, and in the course of a year death results 
from cholseniia, ending in delirium, convulsions, and coma. The princi- 
pal danger from the impacted or incarcerated calculus is that it favors 
the occurrence of an infectious inflammation of the biliary tract, espe- 
cially when impaction is in the common duct, better has shown that 
ligature of the duodenal end of the common bile-duct results in infec- 
tious inflammation of the liver, while ligature of the duct near the liver 
causes no infection of this organ. It is possible that the fever following 
the painful efforts at expulsion of the gall-stone may represent a mild 
infection. The repeated chills, and the intermittent type or prolonged 
continuance of the fever, offer positive evidence of the existence of the 
infection. It is further characterized by hepatic and splenic enlarge- 
ment, perhaps by evidence of a meningitis, an endocarditis, or a nephritis. 
The various infectious inflammations of the biliary tract and their possi- 
bilities have already been described, and it may be added that abscesses 
may be found in remote parts of the body as well as in the biliary tract 
in consequence of the existing infection. 

Diagnosis. — The presence of gall-stones is considered probable when 
the sudden severe attack of localized pain is followed by vomiting, per- 
haps by jaundice, and is associated with enlargement of the liver. The 
severe pain and vomiting of acute gastritis are directly attributable to 
improper food, and the pain from ulcer of the stomach immediately 
follows eating. The early pain from pancreatic hemorrhage and acute 
pancreatitis at times closely resembles biliary colic, especially as there 
may be associated jaundice, but in the pancreatic affections there is 
greater collapse, and the epigastric tenderness is more severe and extends 
to the left. The pain is also more easily relieved, and in the course of 
a few days tender spots from fat-necrosis may appear in the abdomen. 
It may be impossible to exclude a pancreatic calculus, the passage of 
which has produced symptoms not differing from those resulting from 
the passage of gall-stones. The sudden severe pain may suggest peri- 
tonitis from perforation, but in the latter the abdomen rapidly becomes 
rigid and tender and is swollen and tympanitic. The pain of appen- 
dicitis may also be sudden and severe, but is usually seated in the right 



944 



DISEASES OF THE DIGESTIVE APPARATUS. 



iliac fossa, and tenderness exists in the region of the appendix. Eenal 
colic may simulate biliary colic, but in the former the pain extends along 
the course of the ureter, is perhaps referred to the penis or the testicle, 
and blood, sand, or gravel may be found in the urine. The gastric crises 
of locomotor ataxia may simulate biliary colic, but are not attended with 
persistent jaundice or fever, and are especially to be recognized by the 
presence of other symptoms of locomotor ataxia. Lead colic is to be 
excluded by the history of the case, the absence of jaundice or hepatic 
tenderness or enlargement, the obstinate constipation, the retraction of 
the belly, and the peculiar tenseness of the pulse. Small concretions 
may pass with but little pain, yet jaundice follow, and the attack be con- 
sidered as one of catarrhal jaundice. In the latter affection the symp- 
toms at the outset are less sudden, and the jaundice persists for a longer 
time. The probable diagnosis of gall-stones is made certain when the 
calculus is obtained. The fseces, if necessary, for several days after the 
pain has ceased should be freely diluted with water and so thoroughly 
stirred as to contain no fragment larger than a pea. The liquefied 
fseces should be then poured through a fine sieve, when the concretion 
may be obtained. A calculus may have passed through the common duct 
with characteristic symptoms and yet not be discovered by this examina- 
tion, since Naunyn has shown that gall-stones may be decomposed in the 
intestine. 

Eepeated typical attacks of biliary colic may occur and no calculus be 
found, even when the biliary tract is directly explored after a laparotomy. 
The possibility of recurrent attacks of biliary colic even with jaundice, 
especially in nervous persons, perhaps alternating with neuralgic attacks 
elsewhere, and not due to gall-stones, should be recognized, particularly 
when the question of surgical treatment is entertained. The diagnosis 
of gall-stone, the failure to find the calculus, and the persistence of the 
biliary colic suggest that the gall-stone lies in the gall-bladder, the cystic 
duct, or the common bile-duct. Its seat in the gall-bladder is to be in- 
ferred from the persistence of the fever and the localized tenderness, 
especially if jaundice is associated. A number of calculi may be present 
and the gall-bladder be not distended. If the calculus lie in the cystic 
duct, a distended gall-bladder and slight or absent jaundice give im- 
portant evidence of its seat. Increasing jaundice, persisting attacks of 
pain, conspicuous enlargement of the liver, and a gall-bladder of normal 
size are in favor of the presence of calculi in the common duct. The 
significance of the calculus in the production of the acute and chronic 
inflammations of the bile-passages of the liver is indicated by the his- 
tory of early attacks of biliary colic. In like manner antecedent at- 
tacks of biliary colic may lead to the recognition of the gall-stone as the 
cause of an acute obstruction. 

Prognosis. — The immediate attack of biliary colic is rarely fatal 
unless serious disease exists elsewhere, as in the heart or the brain, when 



DISEASES OF THE GALL-BLADDER AND BILE-DUCTS. 945 

fatal collapse or cerebral hemorrhage may occur. Rupture or perforation 
of the biliary tract has also taken place, with a fatal peritonitis. As a 
rule, repeated attacks of colic occur at various intervals without especial 
danger to life unless complicated with the more severe results of an in- 
fectious inflammation. The prognosis is then somewhat dependent upon 
the search for a calculus. If a faceted calculus is found or the search for 
a stone proves negative, other attacks may be expected. A small, round 
calculus not larger than a pea is often the only calculus present. Per- 
sistent jaundice of calculous origin may be relieved after it has existed 
for months, even for three years, as reported by Osier, and the patient 
recover. More frequently death from cholgemia in the course of a year, 
the production of a hypertrophic cirrhosis proving fatal in the course of 
years, or the possible development of cancer of the biliary tract, is to be 
feared. That gall-stones may serve as a cause of cancer of the gall- 
bladder is suggested not only by their frequent concurrence, but also, as 
stated by Gumprecht, by the facts that attacks of biliary colic may for a 
long time precede the symptoms attributable to cancer, and that cancer 
has been found to develop from ulcers and scars of the gall-bladder. The 
latter are frequent results of gall-stones. 

Treatment. — During an attack of hepatic colic the pain is so severe 
as to demand immediate relief, which is best afforded by a hypodermic 
injection of morphine (one-eighth to one-third of a grain) with atropine 
(one two-hundredth to one-eightieth of a grain). Opium should not be 
given by the mouth, or, except in rare cases, by the rectum, absorption 
being too slow and uncertain. The hypodermic injection may be re- 
peated at intervals of half an hour, care being taken that the whole 
amount given shall not be distinctly toxic, lest the relief from pain con- 
sequent upon expulsion of the stone should allow a sudden narcosis. 
The opium should be aided by the general hot bath and by the con- 
tinuous application of moist heat to the hepatic region. In rare cases 
the local use of cold is preferred by the patient and should be practised. 
When the pain becomes unendurable, ether, or even chloroform, may be 
used to mild anesthesia, which by lessening spasm favors the passage of 
the stone. When the paroxysms are frequent and severe, saline purga- 
tives are often of service. 

The objects of the continuous treatment of a case of gall-stones are — 
to prevent, as far as may be, inflammation of the gall-ducts and conges- 
tion of the liver ; to aid, if possible, in the solution of the gall-stones ; 
and especially to prevent the formation of new concretions. Outside of 
the body gall-stones can readily be dissolved by certain medicinal sub- 
stances ; but it is doubtful whether these solvents when given by the 
mouth have any effect. The continued use of them by the profession, 
and the fact that especially during the so-called Carlsbad cure gall-stones 
are frequently passed in considerable numbers without pain, makes, 
however, their trial imperative. 

60 



946 



DISEASES OF THE DIGESTIVE APPARATUS. 



It must further be remembered that bile itself has the power of dis- 
solving some of the substances of which hepatic calculi are made, so that 
the solution of gall-stones would seem to be aided by remedies which 
increase the amount and fluidity of the bile. The method practised by 
Bartholow of injecting these solvents directly into the gall-bladder has not 
found favor, and we have never used it, because it has seemed to us dan- 
gerous. Probably the most famous of the direct solvents is the Durande 
remedy, which consists of three parts of ether and two of turpentine. 
Some practitioners prefer chloroform or ether by itself. These drugs 
should always be given in capsules and upon an empty stomach, so that 
they may reach the liver in as concentrated form as possible. The dose 
should be from ten to twenty minims four to six times a day, according as 
the stomach will bear. Olive oil, six to eight ounces a day, has been much 
used, and occasionally seems to do good ; being a harmless remedy, it is 
certainly worth a trial in individual cases. As bile is the natural solvent 
of its solid constituents, probably no one of the artificial solvents is as 
effective as is the restoration or even exaggeration of the function of the 
liver. 

To aid in the mechanical expulsion of the gall-stone digital manipula- 
tion has been commended by some authorities, but its capabilities for 
harm are far greater than those for good. In cases with great distention 
of the gall-bladder aspiration has been practised ; it usually produces no 
evil effect, but is liable to be followed by an escape of bile and consequent 
severe or even fatal peritonitis. Very rarely, if ever, can any good be 
accomplished by it. 

As the formation of gall-stones is largely the result of improper func- 
tional activity or of loss of functional activity in the liver, and as this 
hepatic torpor is usually due to congestion of the liver or to catarrhal 
inflammation of the gall- ducts, it is evident that such treatment of 
cholelithiasis as is directed to the prevention of the formation of con- 
cretions is practically the same as that of chronic hepatic congestion, 
and is closely allied to that of biliary catarrh. (See articles on these 
subjects.) 

Formerly surgical procedures were justified only when the gall-stone 
was believed to be hopelessly impacted. The results of recent operations 
have, however, been so uniformly good in uncomplicated cases that at 
present the physician is not justified in waiting for more than three or 
four serious attacks of bilious colic, after he is satisfied that a gall- 
stone has lodged in the common duct. Care, of course, must be exercised 
not to mistake attacks of biliary colic produced by the successive forma- 
tion of gall-stones for evidence of the persistent existence of a single 
stone. Too long waiting not only endangers the structure of the liver 
and the health of the patient, but makes the operation itself much more 
difficult and less apt to be a success. Destruction of the gall-bladder, ap- 
parent obliteration of the gall-duct by overlying exudation, and other 



DISEASES OF THE GALL-BLADDER AND BILE-DUCTS. 947 

anatomical changes, may render it impossible for the surgeon to locate the 
diseased part. The operations which are performed are cholecystotomy, or 
incision of the gall-bladder, choledochotomy, or incision into the common 
bile-duct, and cholecystenter ostomy, or union of the intestine with the 
gall-bladder. Of these operations the first is the simplest and the most 
frequently successful, since the cystic duct is often dilated and the stone 
may be removed without opening the common duct, which is deep and 
difficult to close with sutures so as to avoid leakage ; the second appears 
to be the best when the stone is in the common duct and cannot be 
removed through the gall-bladder, although some surgeons prefer chole- 
cystenterostomy with the use of Murphy's button. According to the 
statistics of Murphy, up to April, 1895, in thirty-eight cases of cholecys- 
tenterostomy there had been but one death. The union should be made 
either between the duodenum and the duct or between the colon and the 
duct, as experience has shown that great digestive disturbance follows 
the union with the lower portions of the small intestine. The union be- 
tween the colon and the gall-bladder is much the more easily brought 
about, but it seems physiologically probable that the absence of bile from 
the small intestine must work evil to digestion. The chief objection to 
the operation seems to be the danger of the final closure of the artificial 
fistula between the gall-duct and the intestine : choledochotomy is free 
from such objection, is comparatively easy of performance, and answers 
in the great majority of cases. If during the operation the patient's 
condition becomes such as to make imperative the immediate finishing 
of the operation, no hesitation should be felt in leaving connection be- 
tween the cut duct and the air with a drainage-tube. Almost invari- 
ably the biliary fistula thus connected finally closes, if all stones have 
been removed. In any case of operation a careful, not too violent, 
attempt should be made to crush the stone with the fingers before 
opening the duct (cholelithotripsy) : if success attends the effort the gall- 
bladder should not be opened : if during the subsequent passage of 
fragments there is much pain, hypodermic injections of morphine should 
be given. 

TUMORS OF THE BILIARY TRACT. 

Tumors of the biliary tract may be situated in the bile-passages within 
or without the liver. The former have already been referred to in con- 
nection with tumors of the liver ; the latter deserve independent consid- 
eration. Such tumors are either benignant or malignant. The former 
are the rare fibroma and myxoma of the gall-bladder, and are of no 
practical importance ; the latter is cancer, both primary and secondary, 
relatively rare in the extra-hepatic gall-ducts, although not infrequent 
in the gall-bladder. Musser has recently collected one hundred cases 
of primary cancer of the gall-bladder and eighteen of primary cancer of 
the gall-ducts. 



948 



DISEASES OF THE DIGESTIVE APPARATUS. 



CANCER OF THE GALL-DUCT. 

Primary cancer of the biliary tract usually occurs late in life, in 
women four times as often as in men, and is generally associated with 
gall-stones, although it is a question which is the earlier in development. 
Cancer of the bile-duct usually arises at the duodenal end of the common 
duct. Sometimes it may be found near the junction of the cystic and 
the hepatic duct. 

Morbid Anatomy. — The alterations produced by cancer of the gall- 
duct are often so slight that the growth may be easily overlooked, espe- 
cially since the secondary growths elsewhere, particularly in the liver, 
are frequently extensive. It may represent merely a circumscribed, 
either nodular or oblong, thickening of the mucous membrane and sub- 
mucous tissue near the duodenal papilla. It tends rather towards steno- 
sis than towards ulceration, and its cancerous nature is often question- 
able until a microscopic examination has been made. 

Symptoms. — As a result of the stenosis, complete obstruction occurs 
to the outflow of bile, and persistent and intense jaundice results. Bac- 
terial invasion of the bile- ducts may take place, and a continued or an 
interrupted fever follow. More frequently death occurs in the course of 
three or four months, from cholsemia with profound disturbance of the 
nervous system. It is probably in consequence of such early death that 
ulceration of the neoplasm and extension to the liver or elsewhere, with 
emaciation and debility, are often absent. 

Diagnosis. — The condition is one of rapidly progressing, intense, 
chronic jaundice, the physical examination giving no evidence of the 
cause as in hypertrophic cirrhosis. The negative character of the evi- 
dence, and the fact, as stated by Naunyn, that about one-half of the cases 
of chronic jaundice are due to cancer of the biliary tract, are the factors 
of avail in making the diagnosis. 

Treatment. — The only medical treatment of cancer of the biliary 
tract is palliative. Laxatives and narcotics should be used as necessary. 
Life may sometimes be prolonged and relief obtained by a cholecysten- 
terostomy. 

CANCER OF THE GALL-BLADDER. 

Morbid Anatomy. — Starting as a circumscribed thickening project- 
ing from the inner wall of the gall-bladder, the disease progresses both 
in depth and in circumference until the entire gall-bladder may become 
infiltrated. This viscus is often increased or diminished in size, the 
former perhaps due to accumulation of fluid as well as to the growth of 
the cancer. The wall is frequently nodulated as well as thickened, the 
inner surface extensively ulcerated, perhaps shreddy or papillary, the 
cavity containing more or less fluid, usually opaque gray or yellow, not 
necessarily bile-stained, in which may be shreds of tissue. In the large 
majority of cases one or more gall-stones are present. As a rule, the liver 



DISEASES OF THE GALL-BLADDER AND BILE-DUCTS. 949 

is also cancerous, and the alterations of this organ may be so extreme, 
especially when the changes in the gall-bladder are slight, that the origin 
of the disease in the latter organ is overlooked. Extension to the liver 
may take place directly from the gall-bladder or indirectly by means of 
the blood-vessels or lymphatics. Adhesions and eventually fistulous 
communications may be formed between the gall-bladder and the colon 
or the duodenum. 

Symptoms. — As might be anticipated, the symptoms of cancer of the 
gall-bladder in the majority of cases are identical with those due to gall- 
stones, since the latter are present in the majority of cases of cancer of 
the gall-bladder. The attacks of biliary colic or more or less persistent 
localized discomfort and febrile disturbances occur in the one as in 
the other. Jaundice is less frequent, except late in the disease, when 
gall-stones lie in the gall-bladder. If the latter is enlarged, the duo- 
denum may be compressed, and vomiting, perhaps of blood, take place. 
As the disease progresses, loss of flesh and strength becomes conspic- 
uous, and ascites, perhaps dropsy, may occur, death usually taking place 
within a few months after the malignant nature of the disease is ap- 
parent. If the gall-bladder is enlarged, its outlines may be appreciated 
on physical examination, and nodules may be felt if they are present. 
On the contrary, the cancerous gall-bladder often is shrivelled and inap- 
preciable to the touch. Nodules are likely to be found elsewhere, as 
in the liver or the peritoneum. Aspiration of the enlarged gall-bladder 
may reveal the thickened wall, and permit the escape of an abundant 
albuminous fluid in which blood, bile, or granular detritus may be present. 

Diagnosis. — The uncertainty of the diagnosis is evident from the fact 
that unsuspected cancer of the gall-bladder has frequently first been recog- 
nized after the abdomen has been opened by the surgeon or at the autopsy. 
Its presence may be inferred when, in the course of more or less severe 
biliary colic, with or without jaundice, a rapidly progressing cachexia 
occurs. If complicated with fluid in the peritoneal cavity there is but 
little enlargement of the spleen, since the liquid is due probably to 
cancerous peritonitis. Primary, cancer of the gall-bladder may be con- 
sidered probable when cancer of the liver is to be recognized and there 
is no evidence of antecedent cancer in other parts of the body. 

Treatment. — The medical treatment of cancer of the bladder is 
purely palliative ; if the diagnosis be reached sufficiently early, surgical 
excision is justifiable. 



950 



DISEASES OF THE DIGESTIVE APPARATUS. 



CHAPTER V. 

DISEASES OF THE PANCREAS AND OF THE PERITONEUM. 

DISEASES OF THE PANCREAS. 

HEMORRHAGE. 

Etiology. — Hemorrhage into the pancreas not infrequently occurs 
to a limited extent under a variety of conditions. Among these are 
passive congestion of its veins, acute infectious diseases, and the hemor- 
rhagic diatheses. Extensive hemorrhage, sometimes designated pan- 
creatic apoplexy, is of occasional occurrence, and is at times the result 
of direct injury ; more often there is no obvious cause. It is found 
in adults usually after the middle period of life, rather in the fat than 
in the lean, and has often been observed in persons of alcoholic habits. 

Morbid Anatomy. — The hemorrhage commonly takes place into 
distinct portions of the gland, and the infiltrated regions are of various 
size. The affected part is swollen, firm, and of a dark-purple color, 
though sometimes it is of normal size and of soft consistency. The 
hemorrhage frequently extends beyond the limits of the gland, and the 
blood then may be found in the fat-tissue around the pancreas, within 
the omentum and mesentery, and occasionally in the fat-tissue over the 
kidney. Evidences of bleeding at some earlier period are at times to be 
found as reddish-yellow spots due to the presence of crystals and gran- 
ules of hseroatoidin. 

Symptoms. — Sudden abdominal pain, usually severe, though some- 
times trivial, and immediate collapse, are the only constant symptoms. 
The pain is at times referred to the epigastrium, but often is not sharply 
localized. The diagnosis is generally made after death. 

Prognosis. — Severe forms of pancreatic hemorrhage usually prove 
fatal within twenty-four hours. That recovery may occur is indicated 
by the discovery of blood-pigment in the pancreas when death has 
resulted from disease of other organs, and is demonstrated by recovery 
from a laparotomy at which this lesion has been seen. Usually, if the 
patient survives the immediate effects of the hemorrhage, inflammation 
of the pancreas, with its several possibilities, occurs. 

Treatment. — The treatment of pancreatic hemorrhage consists in the 
meeting of symptoms of collapse at the time of bleeding and in the adminis- 
tration of opiates as required for the relief of pain. Morphine, from one 
eighth to one-fourth of a grain, atropine, from the two-hundredth to 
the one-hundred-and-fiftieth of a grain, strychnine, from one-thirtieth to 



DISEASES OF THE PANCREAS. 



951 



one-twentieth of a grain, and digitalis, from five to ten minims, are to 
be used hypodermically. Alcoholic stimulants and small doses of nitro- 
glycerin are to be given by the mouth. 

ACUTE PANCREATITIS. 

Etiology. — Since acute pancreatitis at times represents the result 
of pancreatic hemorrhage, its etiology is in part that of the hemorrhage, 
and a traumatic cause has repeatedly been observed. Next in importance 
is gastro-duodenal catarrh, especially when recurrent. Acute pancreatitis 
ofbenest occurs in males above the age of fifty years, and in fat persons, 
especially in those who use alcohol freely. 

Morbid Anatomy. — Three anatomical varieties of acute inflamma- 
tion of the pancreas are to be found, — namely, the hemorrhagic, the gan- 
grenous, and the suppurative ; although the transition between the symp- 
toms and lesions of the hemorrhagic and gangrenous varieties is so gradual 
as to make it probable that these are rather stages of a single process than 
independent affections. 

In hemorrhagic pancreatitis the gland is enlarged, generally throughout, 
but sometimes at one end, and the head, when affected, may be half the 
size of the fist. Larger or smaller extravasations of blood of a dark- 
red, almost black, color are present, and the pancreatic duct may con- 
tain a thick, bloody fluid. As in rapidly fatal cases of pancreatic hem- 
orrhage without inflammation, bleeding is frequent into the fat-tissue in 
the vicinity of the pancreas, especially in the mesentery, mesocolon, and 
omentum, and in the region of the left kidney. 

Gangrenous pancreatitis at times is represented by a circumscribed 
necrosis of the gland, which elsewhere presents the appearances of hemor- 
rhagic pancreatitis. When the necrosis is more extensive the entire gland 
may be transformed into a dark-gray, spongy mass loosely attached to 
the abdominal wall. The adjacent peritoneum, especially that of the 
omental bursa, and the serous coat of the neighboring coils of intestine, 
are covered with a fibrinous exudation which in places forms adhesions 
between the apposed surfaces. The cavity of the omental bursa usually 
contains a sero- purulent exudation in greater or less quantity, omental 
bursitis, but evidences of a general peritonitis are rarely found. 

Multiple large and small opaque white spots are often to be found 
within the pancreas and in the subperitoneal fat-tissue, especially in the 
vicinity of the gland, and occasionally in other portions of the abdomen. 
These spots are characteristic of a necrosis of the fat- tissue, dissemi- 
nated fat-necrosis, and often lie immediately beneath the peritoneum, the 
surface of which is then coated with fibrin. The necrotic lobules of 
omental and mesenteric fat and of that in the region of the kidney and 
colon are surrounded by a zone of purulent infiltration which leads to the 
detachment of the necrotic portions, perhaps accompanied by hemor- 
rhage. If the fat-necrosis is in the vicinity of the omental bursa, the 



952 



DISEASES OF THE DIGESTIVE APPARATUS. 



masses of fat- tissue are often discharged into this sac and swim in the 
liquid exudation therein contained. A fistulous communication may be 
established between the cavity of the omental bursa and the interior of 
the stomach or the duodenum. The importance of inflammation of the 
pancreas, especially of hemorrhagic pancreatitis, in the production of the 
fat-necrosis is based not only upon their usual association, but also upon 
the experiments of Langerhans, Whitney, and Hildebrand, who have 
succeeded in producing experimentally multiple disseminated necrosis 
of the fat- tissue either by injection of the minced pancreas into the 
subcutaneous tissue or by direct injury to the pancreas and its ducts and 
blood-vessels. 

In suppurative pancreatitis also the gland is enlarged, but contains 
single or many abscesses of various size. When these reach the sur- 
face the inflammation is extended through the parapancreatic tissue to 
the neighboring peritoneum, at times resulting in a large abscess of the 
lesser omental cavity, which may be discharged into the stomach or the 
duodenum. 

Thrombosis of the splenic vein is not infrequent, and the thrombus 
may be in a state of puriform softening. Abscesses of the liver are at 
times to be found, especially in suppurative pancreatitis. Pleurisy and 
pericarditis are occasional results of the extension through the diaphragm 
of the inflammation from the peritoneum. 

Symptoms. — In the hemorrhagic and gangrenous varieties of pan- 
creatitis the initial disturbances are commonly sudden and severe. 
Abdominal pain is usually the first symptom, and is either persistent 
or paroxysmal ; it is generally referred to the epigastrium, and is some- 
times localized in the region of the pancreas. It is quickly followed by 
vomiting, which may persist even after the contents of the stomach have 
been thoroughly removed, in which case the vomitus is slimy, dark green, 
or black, and may contain liquid or clotted blood. Chilly sensations 
often are present, and the patient may be in a state of prostration or 
collapse for several hours. As a rule, fever soon supervenes, and the 
temperature, although at first only slightly elevated, eventually may be 
as high as 104° F. Hiccough, slight jaundice, and albuminuria have 
been observed, and mild delirium, especially in the later stages of the 
disease, not infrequently occurs. 

In suppurative pancreatitis the initial symptoms are usually neither 
so acute nor so severe, and there may be little or no pain. The fever 
pursues a varying course, and chills not infrequently occur at irregular 
intervals, followed by sudden changes of several degrees in the tem- 
perature. 

During the further progress of acute pancreatitis, whether hemor- 
rhagic, gangrenous, or suppurative, the upper half of the abdomen be- 
comes swollen, tense, and tympanitic. The region of the pancreas and 
sometimes that of the spleen are tender on palpation, and a deep-seated 



DISEASES OF THE PANCREAS. 



953 



resistance may be found near the head of the pancreas, as observed by 
Elliot. The occurrence of a complicating fat- necrosis may be announced 
by the appearance of painful and tender spots in various parts of the 
abdomen. The distention of the abdomen continues to increase either 
locally, perhaps only in the left half, or throughout ; in the latter case the 
entire abdomen at times is extremely swollen, and is tympanitic except 
in the flanks. The abdominal pain becomes general, vomiting persists, 
diarrhoea is frequent, and there is rapid and progressive emaciation. 
During the third or fourth week perforation of the circumscribed peri- 
toneal abscess, the omental bursitis, not infrequently takes place. It is 
made evident by severe lancinating pains, by copious dejections in which 
the sloughing pancreas has been found, and by a rapid diminution in the 
size of the abdomen. 

The course of suppurative pancreatitis may be continued over a period 
of months, in which case ascites and anasarca have been observed. The 
skin has become bronzed, and sugar has been found in the urine. 

Diagnosis. — Sudden abdominal pain, especially when referred to the 
upper abdomen, followed immediately by vomiting and great prostration 
and later by moderate fever and circumscribed resistance in the epigas- 
trium, perhaps in the vicinity of the head of the pancreas, especially when 
occurring in a well-nourished person beyond middle life, should suggest 
acute pancreatitis. Confirmatory evidence is offered by the presence of 
disseminated points of abdominal tenderness, which are suggestive of in- 
cipient fat-necrosis. The differential diagnosis lies between the action of 
an irritant poison, peritonitis from perforation of the stomach or the duo- 
denum, a calculus in the common bile duct, and acute intestinal obstruc- 
tion. The history of the case and the examination of the vomitus permit 
the exclusion of an irritant poison. Perforation of an ulcer of the stomach 
is usually preceded by repeated attacks of characteristic pain and by the 
presence of blood in the vomitus or in the dejections. Biliary colic from 
the passage of a gall-stone is not at once accompanied by symptoms of 
collapse, the relief from pain and distress is often immediate and com- 
plete, and jaundice, if present, is usually early and considerable. 

The affection oftenest mistaken for acute pancreatitis is acute intes- 
tinal obstruction. Its onset is less severe, however, and the epigastrium 
is rarely the seat of the primary localization of the pain and distention. 
In the later stage of acute pancreatitis the tumor due to the frequently 
resulting omental bursitis may be mistaken for cyst of the pancreas. 
The latter is to be excluded by the existence of fever and by the results 
of the examination of the aspirated fluid. 

Prognosis. — Acute pancreatitis is a disease of extreme gravity, death 
usually taking place from shock in the course of a few days after the 
onset of the hemorrhagic variety. When gangrenous pancreatitis is 
concerned, the patient is likely to die in the course of four to eight weeks 
from septicaemia. In suppurative pancreatitis the patient may die in 



954 



DISEASES OE THE DIGESTIVE APPARATUS. 



the course of a few months from septicaemia, or may live for a year 
and then die from progressive exhaustion or from diabetes. The prog- 
nosis is not absolutely hopeless, however, since evidences of antecedent 
acute pancreatitis have been found repeatedly at post-mortem examina- 
tions. In addition, Osier, Korte, and Thayer have reported cases in 
which the presence of hemorrhagic pancreatitis was assured by lapa- 
rotomy and recovery followed. The possibility of recovery from gan- 
grenous pancreatitis, even at a late stage of the disease, is placed beyond 
doubt by the observation of Trafoyer. His patient lived seventeen years 
after the pancreas was discharged from the bowels. 

Treatment. — The treatment of pancreatitis is practically that of a 
localized peritonitis. If in the beginning there are hemorrhage and col- 
lapse, stimulants must be used with an activity proportionate to the 
degree of collapse. Morphine hypodermically is often required for the 
relief of pain. Surgical treatment is demanded when gangrene or sup- 
puration is believed to be imminent, free drainage being necessary, and 
the operation is the more likely to be successful if the peritonitis is con- 
fined, as is usually the case, to the lesser omental cavity. 

CHRONIC PANCREATITIS. 

Etiology. — Chronic inflammation of the pancreas may be the result 
of a long- continued suppurative pancreatitis. More commonly, however, 
it is due probably to a chronic inflammation of the pancreatic duct result- 
ing from persistent or recurrent gastro- duodenal catarrh, especially in 
persons of alcoholic habits. Conditions which give rise to obstruction of 
the pancreatic duct, as calculi or tumors, are also a source of chronic 
pancreatitis. This affection may be limited to a portion of the pancreas 
in connection with ulcer of the stomach or of the duodenum, with caries 
of the spine, and with neighboring tumors or aneurism. Chronic pan- 
creatitis has been found in infants, in whom it is regarded as the result 
of congenital syphilis. 

Morbid Ajsatomy. — The pancreas is usually atrophied either through- 
out or in limited portions, though rarely it is enlarged, and then has been 
mistaken for cancer. The consistency of the diseased part is increased, 
and niay resemble that of cartilage. The surface of the gland is smooth 
or irregular, and the appearance of the section varies according to the 
amount of fibrous tissue present and the associated changes. Reddish- 
gray or grayish-white bands of fibrous tissue traverse the cut surface and 
enclose or replace the more or less atrophied lobules. Fatty degeneration 
of the gland-cells causes a yellow mottled appearance, and white specks 
may be seen, due to the deposition of calcium salts and crystals of fat 
acids. The duct of Wirsung is either unaltered in appearance or is tor- 
tuous, dilated, and often sacculated. The fibrous tissue in the vicinity 
of the pancreas is frequently thickened and indurated. 

Symptoms. — In chronic pancreatitis the symptoms of a chronic 



DISEASES OF THE PANCREAS. 



955 



catarrhal gastritis are present, lasting indefinitely, and frequently ac- 
companied with diarrhoea. Attention is especially to be directed to 
the pancreas as a source of the symptoms when there is deep-seated 
epigastric pain, either mild or severe, and particularly when it occurs in 
paroxysms associated with restlessness, anxiety, and faintness. Ten- 
derness and perhaps resistance on pressure in the region of the pancreas 
have been observed. Jaundice occasionally exists, and is sometimes per- 
sistent from constriction of the common bile-duct by the head of the 
pancreas. The stools are at times colorless, even in the absence of 
jaundice, and may contain fat. There is usually progressive loss of flesh 
and strength. 

Glycosuria has repeatedly been found in chronic pancreatitis, and 
Lancereaux maintained that there was a diabetes due to serious disease 
of the pancreas. Williamson, in a collection of one hundred cases of 
pancreatic lesions in diabetes, found that there was more or less atrophy 
in thirty-nine, and extensive fibrous thickening in thirteen, while in the 
rest of the cases a variety of lesions was present. It is demonstrated by 
the experiments of Yon Mering and Minkowski and De Dominicis that 
total extirpation of the pancreas is always followed by diabetes, while 
if one- eighteenth to one- twelfth of the gland is left the glycosuria is 
moderate, and if more than one-tenth remains there is no glycosuria. It 
is, therefore, probable that the occurrence of glycosuria in chronic fibrous 
pancreatitis depends upon the degree of destruction of the pancreas, and 
that the presence of glycosuria in this variety of pancreatitis indicates 
an extreme degree of destruction of this gland. 

Prognosis. — As there can be no restoration of the destroyed portions 
of the pancreas, the prognosis of chronic pancreatitis is serious : at the 
same time it is to be remembered that extensive atrophy of the pancreas 
may take place, and even a large part of the gland be discharged from 
the bowel, and yet the patient remain in fair health. The occurrence of 
permanent glycosuria with symptoms of chronic pancreatitis makes the 
prognosis hopeless. 

Treatment. — The chief feature in the treatment of chronic pancre- 
atitis is the regulation of diet. All food which requires pancreatic juice 
for its digestion should be reduced to a minimum : hence the necessity of 
restriction in the quantity of fats and starches. The use of carbonated 
waters is to be advised, since Becher has found that they increase the 
pancreatic secretion and its digestive power in dogs. Minced pancreas 
also should be tried, as in Abelmann's experiments the administration of 
pancreatin after extirpation of the pancreas promoted the digestion of fat. 

PANCREATIC CALCULI. 

Etiology. — Catarrhal inflammation and retention of secretion in the 
duct of Wirsung are probably of chief importance in the origin of cal- 
culi in the pancreas. The retention of secretion may be due to obstruc- 



956 



DISEASES OF THE DIGESTIVE APPARATUS. 



tion of the duct from some external cause, as chronic pancreatitis or 
tumor of the gland. 

Morbid Anatomy. — Few or niany, even more than a hundred, cal- 
culi may be present, varying in size according to their number. Soli- 
tary calculi may be as large as walnuts, and the smallest concretions are 
mortar-like. The calculus is generally rounded or oblong, rough or 
smooth, and may be continued by lateral projections from the wall into 
the primary branches of the duct. It is of a grayish color, and easily 
disintegrated. The pancreatic duct and its branches are usually dilated, 
and atrophy and induration of the gland are frequently associated. Ul- 
ceration of the wall of the duct may be present, and even fistulous open- 
ings into the stomach, duodenum, or peritoneal cavity. Cancer of the 
pancreas is rarely an accompaniment. 

Symptoms. — Calculi often are found unexpectedly in the pancreas at 
a post-mortem examination, but in many cases there are antecedent dis- 
turbances due to a gastro- duodenal catarrh. The first symptom especially 
suggestive of the presence of a pancreatic calculus is pain, without espe- 
cial tenderness, due probably to the displacement of the calculus. It 
manifests itself either as a sharply defined feeling of pressure or discom- 
fort in the epigastrium or as an intense spasmodic pain continued along 
the left costal cartilages towards the spine and the left shoulder-blade. 
This pancreatic colic resembles biliary colic, and jaundice is occasionally 
associated. Indeed, it may be impossible for the patient himself to dis- 
criminate between pancreatic and biliary colic, as in the case reported by 
Minnich of a patient who passed at different times gall-stones and pan- 
creatic calculi. When the calculi are incarcerated, dilatation of the duct 
of Wirsung and fibrous pancreatitis are the usual results, and in rare 
instances a cyst of the pancreas is formed. There is progressive loss of 
flesh and strength, diarrhoea is frequent, the stools often contain fat acids, 
undigested muscular fibres are abundant, and pancreatic concretions have 
been found in the dejections. Occasional or permanent gtycosuria also 
may be present. 

Diagnosis. — The diagnosis is based upon the persistence or frequent 
occurrence of more or less severe attacks of deep-seated epigastric pain, 
radiating to the left and simulating biliary colic, though usually with- 
out jaundice. It is confirmed by the discovery of typical concretions in 
the stools. If the characteristics of pancreatic diabetes — namely, glyco- 
suria, polyuria, polyphagia, polydipsia, and loss of flesh and strength 
— are preceded by frequent attacks of pancreatic colic, the presence of 
concretions and of chronic inflammation of the pancreas is rendered 
probable. 

Prognosis. — Pancreatic calculi are sometimes spontaneously evacu- 
ated, either from the intestine — perhaps because of the establishment of a 
fistulous communication between the pancreatic duct and the stomach or 
intestine — or through the abdominal wall, as seems probable in the case 



DISEASES OF THE PANCREAS. 



957 



reported by Capparelli. Fatal peritonitis may follow perforation of the 
pancreas into the peritoneal cavity. Usually, however, the duration 
of life is unaffected by the calculi, or the prognosis becomes that of 
chronic pancreatitis or of pancreatic cyst. 

Treatment. — Attacks of pancreatic colic are to be treated like 
biliary colic, by the local application of heat, the subcutaneous injection 
of morphine, and the inhalation of ether or chloroform. The treatment 
of the ultimate results of pancreatic calculi is that of chronic pancreatitis 
or of pancreatic cyst. The possibility of the successful removal by the 
surgeon of pancreatic calculi before permanent alterations in the pancreas 
have taken place should always be borne in mind. 

CYST OF THE PANCREAS. 

This term is intended usually to indicate a cavity formed by the 
dilatation of the duct of Wirsung, the wall being composed of fibrous 
tissue containing portions of the glandular structure of the pancreas, and 
the contents being a fluid presenting the characteristics of the pancreatic 
secretion. 

Critical investigation, however, of many of the reported cases of pan- 
creatic cyst makes it probable that this term has been applied often to 
collections of fluid near the pancreas but wholly outside of its boundary ; 
and in rare instances multilocular cysts occur in the pancreas which have 
no apparent connection with the pancreatic duct or its branches. 

Etiology. — Pancreatic cyst may be of congenital origin, for Ei chard- 
son extirpated a probable cyst of the pancreas from an infant fourteen 
months of age. Usually, however, cysts of the pancreas are found in 
adults, and with equal frequency in each sex. The common cause is 
obstruction in the course of the pancreatic duct, either from inflamma- 
tion of its wall or of the pancreas around the duct, or from the pressure 
of tumors, the impaction of calculi, or possibly, as in the case reported 
by Durante, the presence of a lumbricus in the duct. Although an 
important place in etiology is usually assigned to local injury, it is 
probable, as suggested by Lloyd, that, as a rule, the cyst which subse- 
quently appears in the region of the pancreas is an omental bursitis, — 
that is, an encysted peritonitis in the lesser omental cavity. The injury 
is likely to produce a hemorrhagic pancreatitis, and the extension of 
the inflammation to the peritoneal covering of the pancreas is an efficient 
cause of the encysted peritonitis, which may closely simulate in its 
physical characteristics a cyst of the pancreas. Multiple cysts of the 
pancreas are usually due to obstruction of the smaller branches of the 
pancreatic duct, but Salzer and Hartmann have reported cases of cystic 
tumor of the pancreas which correspond apparently to the cystoma of 
the ovary, and some of them are of a malignant nature. 

Morbid Anatomy. — Cysts of the pancreas are situated behind the 
stomach, being separated from it by the two la3^ers of peritoneum which 



958 



DISEASES OF THE DIGESTIVE APPARATUS. 



form the walls of the omental bursa, and which are sometimes fused. 
When small they may be found on either side of the median line, but 
when large they develop more to the left than to the right. The 
stomach is then pushed upward, although in rare instances it may lie 
upon or below the tumor. The transverse colon extends across the cyst 
or is displaced downward. The cysts are single or many, and are 
sometimes multilocular. They originate in any part of the gland, and 
vary in size from those scarcely visible to the naked eye to one as large 
as the pregnant uterus at full term and extending from the ensiform 
cartilage to the pubic symphysis. The larger cysts may result from the 
fusion of smaller cavities, and are of a spherical shape, the structure 
of the pancreas being lost in that of the cyst. At times the gland may 
resemble a bunch of grapes, from the presence of numerous and closely 
joined cysts. The inner surface of the wall of the cyst is smooth or 
trabeculated, and is lined with cylindrical epithelium. Papillary out- 
growths at times project into the cavity, and openings in the wall com- 
municating with smaller cysts are frequently to be seen. The duct of 
Wirsung, in certain cases, is to be followed to the interior of the cyst 
both from the head and from the tail of the pancreas, but frequently 
ends blindly when traced from the duodenum to the cyst. The contents 
of the cyst may be upward of four gallons in quantity. They are of a 
pale gray color, somewhat turbid, viscid or watery, of alkaline reaction, 
and of a specific gravity between 1010 and 1024. Microscopical exami- 
nation shows leukocytes, fattily degenerated epithelium, fat- drops, and 
crystals of cholesterin and of fat acids. The fluid presents some or all 
of the physiological characteristics of the pancreatic secretion, but the 
older the cyst the less likely are the contents to show all of them. Blood 
is sometimes present. 

The larger the cyst the more extensive is the atrophy of pancreatic 
tissue, but portions of the gland are to be found within or upon the wall. 
When rupture takes place the contents escape into the stomach, into the 
colon, or into the general peritoneal cavity or that of the omental bursa. 
In the latter case a large cystic tumor of this structure may be formed, 
the contents having the properties of pancreatic juice, and yet a large 
portion of the pancreas may remain but little altered. 

Symptoms. — There may be no antecedent symptoms, the cyst being 
discovered accidentally during convalescence in childbirth or from 
typhoid fever. Usually, however, there is epigastric pain, often per- 
sistent perhaps for months or years. It is not infrequently interrupted 
by paroxysms of pain which are without obvious cause or follow errors 
in diet, and which are sometimes so severe as to be associated with symp- 
toms of collapse. The pain usually starts near the ensiform cartilage 
and extends downward or to the left, and may be continued into the left 
shoulder and perhaps into the left half of the face. In addition to the 
pain there is frequently vomiting, diarrhoea, or constipation, and the 



DISEASES OF THE PANCREAS. 



959 



patient complains of fulness in the epigastrium, which is perhaps tender. 
Eecurrent attacks of intestinal hemorrhage sometimes occur. The gen- 
eral nutrition may be well maintained, or there may be loss of flesh and 
strength. 

The cyst is usually first noticed in the left half of the epigastrium, 
but may be discovered in the left lumbar region. Its growth is apt to be 
slow, and the cyst after remaining at a stand-still for years may suddenly 
increase to a large size within a few weeks. On palpation the tumor 
is smooth, rounded, resistant, and has a slight mobility. It frequently 
transmits the aortic pulsations. It is inelastic except when superficial, 
and then fluctuation is at times to be recognized. It is dull on percussion 
where not overlain by stomach or intestine. On auscultation a souffle 
from compression of the aorta is frequently transmitted. 

"When the cyst attains a considerable size the dull epigastric pain or 
sense of pressure is usually constant. The disturbance of digestion be- 
comes persistent, and loss of flesh and strength is progressive. Fat and 
abundant undigested muscular fibres have been observed in the faeces, 
and sugar and albumin have been found in the urine. 

Eventually mechanical disturbances are caused by the cyst even if the 
resulting atrophy of the pancreas does not interfere with digestion and 
assimilation. There are difficulty of breathing from interference with 
expansion of the lungs, ascites from pressure upon the portal vein, and 
anasarca of the lower half of the body from pressure upon the inferior 
vena cava. Intestinal obstruction has resulted from the pressure of the 
cyst upon the bowels. 

Diagnosis. — The presence of a cyst of the pancreas is to be inferred 
from the discovery in the epigastrium or left hypochondrium of a smooth, 
rounded tumor, slightly movable, especially in the vertical direction, 
and separated from the liver and spleen by a resonant area unless the 
tumor is of very large size. Its position behind the stomach and colon 
is made evident by inflation of these organs, and its cystic nature is 
readily determined by aspiration. The pancreatic nature of the cyst 
is rendered probable if the aspirated fluid emulsifies fat, saccharifies 
starch, and digests albumin and fibrin. Yon Jaksch and Boas, however, 
maintain that the diastasic and emulsifying properties of the pancreatic 
juice may be present in other liquids, and that the peptonizing property 
is frequently absent from the contents of an unquestioned pancreatic 
cyst. The presence of blood in the aspirated fluid is of no diagnostic 
value, since it is inconstant. Even when blood is present in a fluid con- 
taining one or more of the properties of the pancreatic secretion and 
drawn from a cyst in the region of the pancreas, it does not follow that 
there is a pancreatic cyst. In such cases there is frequently the history 
of a local injury, and it is not unlikely that a laceration of the pancreas 
occurs, followed by an omental bursitis, and that pancreatic secretion 
becomes mixed with blood and peritonitic exudation. 



960 



DISEASES OF THE DIGESTIVE APPARATUS. 



The tumor may be confounded with aneurism of the aorta, dropsy of 
the gall-bladder, cystic tumors of the kidney, hydronephrosis of the left 
kidney, and large cysts of pelvic origin. Aneurism of the aorta is to be 
excluded by the absence of expansile pulsation and the disappearance of 
the transmitted aortic beat when the patient is placed on the hands and 
knees. The distended gall-bladder is in the right half of the abdomen, 
is intimately connected with the liver, and changes position with the 
movements of the diaphragm. Multilocular cystic kidneys are bilateral, 
and although hydronephrosis may be limited to the left kidney, it then 
forms an oblong tumor in the lumbar region, and is crossed by the colon 
rather in the vertical than in the transverse direction. Extremely large 
pancreatic cysts may be confounded with cysts of the ovary or the broad 
ligament, but the history of the case will show that the distention of the 
abdomen proceeds from above downward. Pelvic cysts lie immediately 
beneath the abdominal wall, and are to be felt on vaginal examination. 
The fluid from them is often gelatinous and does not present the physi- 
ological characteristics of pancreatic juice. 

It may be impossible to discriminate absolutely between cysts of the 
pancreas and encysted fluid in the omental bursa or in the mesentery, 
such as result from omental bursitis, echinococcus, lymphangioma, or 
chylangioma. The characteristics of the aspirated fluid may permit the 
elimination of suppurative peritonitis, echinococcus cyst, and chylan- 
gioma, but are insufficient to exclude a serous peritonitis of the omental 
bursa, especially if blood is present in the exudation. 

Prognosis. — A cyst of the pancreas has been known to be present for 
twenty years and yet cause but slight disturbance. Digestion may be inter- 
fered with but little even when large cysts are present. The prognosis 
becomes grave in case diabetes is present. 

Treatment. — Pancreatic cysts when producing permanent or serious 
discomfort are to be treated surgically. The result of the operation is 
usually favorable unless diabetes exists. 

CANCER OF THE PANCREAS. 

Although benign tumors are found in the pancreas, they are rare and 
of no clinical interest. The malignant growths are lymphoma, sarcoma, 
and cancer, which produce similar symptoms and are conveniently 
described as cancer. 

Etiology. — In spite of the assertion that cancer of the pancreas occurs 
in about six per cent, of all cases of cancer, Mirallie has been able to col- 
lect but one hundred and thirteen cases of primary cancer of this viscus. 
Nearly two-thirds of them are in males, usually in the middle third of 
life, although pancreatic cancer has been found at birth. 

Morbid Anatomy. — The head of the pancreas is the part most fre- 
quently diseased. The growth may be circumscribed or be infiltrated 
throughout the gland. The tumor is usually rounded, at times as large 



DISEASES OF THE PANCREAS. 



961 



as a child's head, and varies in color and consistency according to the 
quantity of fibrous tissue, the number of epithelioid cells, the degenera- 
tions they have undergone, the vascularity and hemorrhages, and the 
degree of jaundice present. The unaffected portion of the gland may 
be normal in appearance, or be atrophied from cystic dilatation of the 
duct of Wirsung. Pressure upon the common bile-duct is frequent. The 
disease often extends to the neighboring lymphatic glands, to the liver 
and spleen, and to the peritoneum. Fibrous adhesions are common be- 
tween the diseased pancreas and the surrounding organs. 

Symptoms. — The existence of cancer of the pancreas may first be 
made known at the autopsy. As a rule, disturbances of digestion refer- 
able to the stomach or the duodenum precede for years the symptoms 
more directly attributable to the cancer. These are epigastric pain and 
jaundice. The pain not infrequently occurs in paroxysms, especially 
at night, and is very severe in at least one-half the cases, and then may 
be accompanied by symptoms of collapse. The pain radiates in various 
directions as a cceliac neuralgia, and when extending into the back has 
repeatedly been mistaken for lumbago. "When jaundice is present it 
may follow an attack of pain resembling biliary colic, but it persists and 
is associated with enlargement of the liver and gall-bladder. 

The characteristic feature of cancer of the pancreas is a tumor in 
the region of the gland ; but this is discovered in less than one-half 
of the cases. It lies near the median line, above the navel, and is deep- 
seated. It is but slightly movable, and varies in outline, density, and 
sensitiveness. The pulsation of the aorta is usually transmitted. The 
tumor by pressing upon the portal vein may cause ascites, and then may 
first be discovered after withdrawal of the fluid from the abdominal 
cavity. Pressure on the inferior vena cava causes anasarca of the lower 
half of the body. Pressure upon the duodenum may induce dilatation 
of the stomach or lead to symptoms of intestinal obstruction. Cancer 
of the tail of the pancreas is a cause of hydronephrosis of the left kidney, 
from pressure upon the ureter. 

The appetite may be unaffected or be even excessive. When there is 
vomiting, blood, free fat, and fatty acids may be found in the vomitus. 
Constipation or diarrhoea may occur. Blood is sometimes present in the 
stools, but liquid or solid fat or fat acids are rarely found in them. Most 
important as evidence of disturbed pancreatic digestion is the presence 
of abundant undigested muscular fibres in the dejections when there is 
no diarrhoea. The urine is sometimes increased in quantity, and may 
contain albumin ; sugar is at times present, and the glycosuria may dis- 
appear shortly before death. In the later stages of the disease the gen- 
eral nutrition may be but slightly affected, and death occur suddenly 
from gastro-intestinal or intra-peritoneal hemorrhage. More commonly 
there is a progressive, rarely rapid, loss of flesh and strength, and death 
occurs either gradually, or suddenly from pulmonary embolism. 

Gl 



962 



DISEASES OF THE DIGESTIVE APPARATUS. 



Diagnosis. — The recognition of cancer of the pancreas depends largely 
upon the discovery of a tumor in the region of the pancreas, accompa- 
nied by symptoms of obstruction of the pancreatic duct and the common 
bile-duct. The relation of the tumor to the stomach and the colon is to 
be determined by inflation of these organs. Evidence of obstruction 
of the common bile-duct is afforded by abundant undigested muscular 
fibres after a meat diet and when there is no diarrhoea ; also by the 
absence of a dark greenish-brown color of the urine when a drachm 
of salol is taken in divided doses in the course of twenty-four hours, 
and by a diminished quantity of indican in the urine. Neither fat in 
the stools, lipuria, nor glycosuria is of value in the diagnosis of cancer 
of the pancreas. 

Cancer of the pylorus is more freely movable, is associated usually 
with a dilated stomach, and is generally unaccompanied by jaundice. 
Cancer of the duodenum is not to be differentiated from cancer of the 
pancreas, and many of the reported cases of duodenal cancer are probably 
cases of cancer of the head of the pancreas. In cancer of the transverse 
colon inflation of the large intestine is difficult, symptoms of intestinal 
obstruction are present, and there is likely to be abundant indican in the 
urine. In cancer of the liver there is usually enlargement of this organ, 
and jaundice and ascites are frequently associated. 

Prognosis. — Cancer of the pancreas usually progresses rapidly after 
the discovery of the tumor, death taking place, as a rule, within a year. 
Jaundice and ascites often precede death by a few weeks only. 

Treatment. — The symptoms of cancer of the pancreas which es- 
pecially require treatment are pain, to be relieved by morphine, and 
perhaps ascites, which, if a cause of mechanical discomfort, should be 
treated by abdominal puncture. 

DISEASES OF THE PERITONEUM. 

INTRA-PERITONEAL HEMORRHAGE. HEMATOCELE. H/EMO- 

PERITONEUM. 

According as hemorrhage into the peritoneal cavity is free or cir- 
cumscribed, so the terms hseinoperitoneuni and hematocele are used. 
In the former the hemorrhage may reach any part of the peritoneal 
cavity ; in the latter the progress of the bleeding is limited by adhesions. 

Etiology. — Hemoperitoneum is caused by penetrating wounds of 
the abdominal wall or viscera, whether due to knife, bullet, or surgical 
instrument ; also by laceration of the liver, spleen, kidneys, or intestine. 
Hemorrhage into the peritoneal cavity may likewise result from rup- 
tured aneurisms of the aorta and its larger abdominal branches, from 
omental and mesenteric aneurisms, and from the tearing of large and 
thin- walled blood-vessels in malignant disease of the liver, pancreas, and 
ovary. Although scurvy, purpura, haemophilia, phosphorus poisoning, 



DISEASES OF THE PERITONEUM. 



963 



and certain infectious diseases may be productive of intra-peritoneal 
hemorrhage, the latter is so slight as not to be of practical importance. 

Varicose veins of the ovary or of the broad ligament may rupture, 
either producing at once a hematocele or causing a hematoma within 
the broad ligament, whose subsequent tearing produces the hematocele. 
The escape of menstrual blood through the open end of a normal tube, 
or through the tube cut across in the removal of a pelvic tumor, or from 
a tube dilated with blood, hcemosalpinx, in consequence of obliteration of 
the fimbriated end, sometimes causes hematocele. 

Rupture of the new-formed blood-vessels in the membrane resulting 
from a hemorrhagic pelvic peritonitis is still to be included among the 
causes of hematocele, although its importance has become lessened since 
the surgeons have shown the far greater etiological importance of ectopic 
gestation. 

The most important as well as the most frequent of the remediable 
causes of hemoperitoneum is ectopic pregnancy, which is also the most 
important cause of hematocele. The foetus may be present in any part 
of the dilated Fallopian tube, usually in that beyond the uterus. The 
time at which the hemorrhage is to take place is chiefly dependent upon 
the situation and the age of the foetus. The wall of the tube becomes 
weakened, usually during the first three months of pregnancy, although 
the immediate rupture of the tube may result from blows, falls, or 
strains, and may occur at or about a menstrual period or during sexual 
excitement. 

Morbid Anatomy. — In fatal cases of hemoperitoneum in consequence 
of the usual cause, the pelvis contains clotted blood which extends up- 
ward between the abdominal wall and the lowermost coils of intestine. 
The hematocele forms a rounded tumor which may be larger than a 
child's head, but more frequently is about the size of an orange. It usu- 
ally lies behind the uterus and the broad ligament, although sometimes 
in front, and may extend into the abdominal cavity. The peripheral 
portions of the tumor are composed of old or fresh blood-clots entangled 
in fibrous adhesions and adherent to the thickened peritoneum. The 
centre contains fresh blood, liquid or clotted, with or without adhesions, 
and perhaps a foetus or other products of gestation. In both hemoperi- 
toneum and hematocele a dilated and ruptured Fallopian tube is likely 
to be found. 

Symptoms. — The disturbances resulting from intra-peritoneal hemor- 
rhage vary in accordance with the amount of blood extravasated and the 
length of time during which hemorrhage has taken place : hence they 
may be those of a sudden and extreme loss of blood, or of protracted and 
slight, perhaps recurring, hemorrhage, or of the latter condition termi- 
nating in the former. 

Pain is generally an early symptom, although, as a rule, of but little 
severity. Its importance consists in attracting attention to the place ironi 



964 



DISEASES OF THE DIGESTIVE APPARATUS. 



which the hemorrhage proceeds, and it is especially significant in the 
possibly pregnant female, since it is ordinarily sufficiently frequent and 
severe to lead her to seek for relief. The hemorrhage may be so extreme 
that the patient in apparent health and without obvious cause becomes 
rapidly enfeebled and dizzy ; her face is pale and her pulse rapid and 
weak. If the bleeding is more profuse, the patient is restless and anx- 
ious, with a hollow and husky voice, a cold and clammy skin, a pulse 
scarcely to be felt, and a prolonged and infrequent respiration. 

Physical examination may give no evidence of the seat or extent of 
free hemorrhage into the peritoneal cavity. If dulness exists, it is such 
as lies within normal limits. Palpation or bimanual exploration may 
meet with no more resistance than that afforded by intestinal coils with 
liquid contents. If ectopic pregnancy is the cause, and the tube is 
ruptured, there may be no physical evidence of its pathological con- 
dition. When the hemorrhage is limited by adhesions, the symptoms 
and signs are those of hematocele. The patient is likely to have had 
antecedent pelvic peritonitis, whether mild or severe, and there is a 
history of more or less pelvic disturbance. If previously pregnant, a 
considerable interval is likely to have occurred since the birth of the last 
child. The patient has been exposed to impregnation, but the frequent 
occurrence of irregular, perhaps profuse, flowing, has opposed the idea 
of pregnancy. Nausea and fulness of the breasts may be present or 
absent. If occasional twinges of pain have preceded, they are likely to 
have been attributed to intestinal disturbance. A more profuse metror- 
rhagia may have been accompanied by the discharge of a membrane, — 
the exfoliated, hyperplastic, uterine mucous membrane. 

With such antecedents the formation of the hematocele is favored, 
and its presence is rather indicated by pressure upon the neighboring 
parts than by symptoms of collapse or the occurrence of severe pain. 
Within twenty -four hours the hematocele may attain a size sufficient to 
produce frequency of micturition, irritability of the rectum, or pain and 
abnormal nervous sensations in the legs, according as the pressure is 
upon the bladder, the rectum, or the pelvic plexuses of nerves. Yaginal 
examination then indicates the presence of a tender, rounded, elastic 
tumor at one side, behind or in front of the uterus. The uterus is likely 
to become somewhat enlarged and soft, lying nearer the symphysis or the 
hollow of the sacrum according to the seat and size of the hematocele. 
Not infrequently the death of the foetus is the result of the hemorrhage, 
which then ceases, the extravasated blood being often absorbed. The 
symptoms which ensue are those of a mild localized pelvic peritonitis, 
and consist in a slightly elevated range of temperature lasting a few 
days, hypogastric and vaginal tenderness persisting for some time, and 
moderate tympanitic distention of the abdomen. If the blood is ab- 
sorbed, a diffuse induration in the vicinity of the uterus may remain 
in its place. If the foetus continues to grow, the hemorrhages become 



DISEASES OF THE PERITONEUM. 



965 



more frequent and severe, the hematocele increases in size, and symp- 
toms of progressive anaemia are associated with the febrile disturbance 
and localized pain. 

The tendency is now towards a perforation of the hematocele into the 
rectum or elsewhere in the intestine, into the vagina, or, more rarely, into 
the bladder. Perforation into the rectum is preceded by frequent mucous 
discharges and tenesmus, and a soft and especially tender spot may be 
found on rectal examination of the surface of the tumor. The discharge 
of the contents of the hematocele into the rectum is likely to be followed 
by an immediate relief to the symptoms, which relief may become per- 
manent with the disappearance of the hematocele. On the other hand, 
the admission of the rectal contents into the hematocele is likely to pro- 
duce gangrene of the wall of the latter, with a fatal peritonitis. If per- 
foration takes place into the intestine elsewhere than in the rectum, a 
similar fatal peritonitis may result or fistule be established between the 
hematocele and the ileum or cecum and the rectum. Perforation into 
the vagina is less frequent than into the rectum, and is followed by like 
possibilities. Perforation into the bladder usually causes cystitis and 
pyelonephritis. 

Diagnosis. — The diagnosis of intra peritoneal hemorrhage is based 
upon the occurrence of sudden, more or less severe collapse in an ap- 
parently healthy person, associated with pain and tenderness in the lower 
abdomen or pelvis. Although such symptoms suggest peritonitis from 
perforation, the rapid progress of the anemia excludes this diagnosis. 
The source of the hemorrhage being concealed at the outset, the history 
of the case becomes important in calling attention to the gastric, intestinal, 
uterine, or urinary source of the hemorrhage. In severe gastric or intes- 
tinal hemorrhage, pain in the region of the stomach or duodenum or 
symptoms of typhoid fever or evidences of fibrous hepatitis are likely to 
have preceded, or blood is found in the vomit and stools. Blood in the 
urine or in the vagina would point towards the source of the hemorrhage 
in the genito-urinary apparatus. Hemorrhage from tumors of the liver, 
pancreas, or ovaries is likely to occur in the later stages of these affec- 
tions and after characteristic symptoms have been manifested. Sudden 
collapse and pain may be due to the rupture or to the twisting of the 
pedicle of an ovarian cyst, especially the latter, in which case the symp- 
toms of anemia are very conspicuous. The physical examination will 
disclose the presence of a tumor of such size as to have been previously 
recognized or of such rapid and extreme development as to exclude the 
idea of hemorrhage alone. 

In hemoperitoneum there is usually no satisfactory physical evidence 
of diagnostic value in determining the presence of blood. On the con- 
trary, if the hemorrhage is circumscribed, a tumor is to be found and its 
outlines are to be determined by bimanual examination. The tumor may 
be simulated by a hematoma of the broad ligament, but this is at the 



966 



DISEASES OF THE DIGESTIVE APPARATUS. 



side of the uterus and lacks the severe symptoms of pain and collapse, 
although later these may follow the rupture of the hematoma, which pro- 
duces either hsemoperitoneum or hematocele. A retroflexed pregnant 
uterus, uterine fibromyomata, small ovarian tumors, pregnancy, or re- 
tained menses in a rudimentary horn may simulate a hematocele. The 
nature of the tumor may be suspected if the possibility and signs of preg- 
nancy are absent. The history of pregnancy and the catheter or sound 
in the bladder permit the diagnosis of retroflexion of the pregnant uterus 
to be made. Although a distended uterine horn may closely resemble the 
hematocele in history, symptoms, and signs, the tumor is usually lateral 
and the dilated crescentic os is a part of the tumor. A circumscribed 
perimetritis or a salpingitis may also resemble the hematocele in symp- 
toms, seat, and physical characteristics, although the symptoms are less 
violent and less rapid and anaemia is absent. The use of the aspirator in 
case of need will show whether the tumor is composed of blood or of in- 
flammatory exudation. 

Prognosis. — Small intra peritoneal hemorrhages are of but little con- 
sequence, since blood is readily absorbed by the peritoneum. If the 
hemorrhages are sufficiently large, death occurs within a day or two, 
at times within a few hours. Small hematoceles are usually readily 
absorbed. Large hematoceles may also be absorbed, although months 
are necessary for this to take place. The prolonged illness attend- 
ing absorption becomes grave if perforation and evacuation of the con- 
tents of the hematocele, with the risks of putrefaction and gangrene, 
occur. If the patient recovers, fibrous adhesions, obliterated tubes, 
and dislocated organs are likely to be left and cause dysmenorrhea, 
sterility, and chronic invalidism. 

Treatment. — There is no medical treatment for rapidly progressing 
hemorrhage into the abdominal cavity. If the hemorrhage is circum- 
scribed, the patient should be made comfortable, the strength supported, 
and the absorption of the clot favored by rest and proper care. Serious 
recurring hemorrhages, threatening life, or producing large tumors, or 
progressing with symptoms of impending perforation or of septicaemia, 
require surgical treatment. Zweifel has found that the mortality of 
one hundred and forty- four cases of hematocele under medical treatment 
was sixteen and six-tenths per cent. Of sixty-six cases treated by 
puncture the mortality was fifteen and one-tenth per cent. Of thirty 
cases treated by incision ten per cent. died. A still lower mortality 
follows the treatment of hematocele by abdominal section, although 
the series of cases thus treated includes those of mild as well as of 
severe hemorrhage, the large majority of the cases needing no surgical 
treatment. Martin states that of two hundred and sixty-five cases of 
ectopic gestation treated expectantly thirty-six per cent, recovered and 
sixty-three per cent, died, while of five hundred and fifteen operated 
upon seventy-six per cent, recovered and twenty -three per cent. died. 



DISEASES OF THE PERITONEUM. 



967 



HYDROPERITONEUM. ASCITES. ABDOMINAL DROPSY. 

Accumulation of transuded fluid into the peritoneal cavity takes place 
under several conditions, and is the symptom of various diseases. 

Etiology. — Two varieties of dropsy are usually recognized, the me- 
chanical and the cachectic. The former is the result of obstruction to the 
venous outflow, causing increased transudation, or of obstruction to the 
lymph-current, preventing absorption. Cachectic ascites occurs when 
the peritoneal endothelium is abnormal and interferes both with venous 
transudation and with lymphatic absorption. The immediate mechanical 
causes of abdominal dropsy are general or local. Conspicuous among 
the former is obstruction to the passage of blood through the heart, as 
in uncompensated valvular disease and cardiac weakness, pulmonary 
emphysema, and fibrous pneumonia. The most important local cause 
is obstruction to the passage of blood through the liver, whether from 
fibrous hepatitis, malignant disease of the liver, thrombosis of the trunk 
of the portal vein, or pressure upon the latter by pancreatic tumors or 
enlarged lymphatic glands or its constriction by peritonitic thicken- 
ings and adhesions. The pressure of tumors upon the lymphatics and 
the hepatic vein or upon the inferior vena cava or the root of the 
mesentery is likewise a local cause of ascites. The immediate cause 
of cachectic ascites is the disturbed nutrition of the peritoneum, such 
as occurs in emaciating diseases, amyloid degeneration, nephritis, and 
chronic malaria. 

Chronic fibrous hepatitis or cirrhosis of the liver is the most frequent 
cause of abdominal dropsy. The enlarged abdomen occurring in peri- 
toneal tuberculosis and cancer is a manifestation rather of peritonitis 
than of dropsy. 

Ascites takes place at all periods of life, and may even interfere with 
the birth of the child, although it is of more frequent occurrence in the 
adult. 

Morbid Anatomy. — The peritoneum may show no abnormal ap- 
pearances, or it is slightly thickened and opaque, especially in patches. 
The subperitoneal fibrous tissue may likewise be thickened and indurated. 
Such thickenings are to be regarded rather as complications than as essen- 
tials. The ascitic fluid or dropsical effusion varies in quantity up to 
several gallons. It is commonly of a pale yellow color, with a slightly 
greenish tint, though it may become dark green from the presence of 
bile-pigment, or red or reddish brown from that of blood. It is usually 
clear, but may be opalescent, especially after its removal during life, in 
consequence of the precipitation of some probably albuminoid constit- 
uent. It is either alkaline or neutral, is of a watery or a viscid consist- 
ency, and has a specific gravity of 1010 to 1015. Its chemical character- 
istics are practically those of blood-serum. It contains from two to two 
and five-tenths per cent, of albumin, and the ready determination of the 



96S 



DISEASES OE THE DIGESTIVE APPARATUS. 



percentage of this constituent is of considerable importance. The greater 
the quantity of albumin contained in free fluid in the peritoneal cavity, 
the more likely is its origin to be inflammatory ; the less the percentage 
of albumin, the more likely is the fluid to be ascitic. The lowest percent- 
ages are found in cachectic ascites, the highest percentages in cancerous 
peritonitis. The quantity of albumin present is approximately deter- 
mined by the use of the urinonieter, and the accompanying (able, a modi- 
fication of that of Buneberg, indicates the relation of the specific gravity 
to the percentage of albumin in free fluid from the abdominal cavity, and 
its etiology. 



Specific Gravity. Percentage of Albumin. Cause 

1008 0.2 \ _ _ . 

1009 0.6 I Hydremic ascites. 

1010 1.0 l 

jQ-Q l 3 J Portal obstruction. 

1012 1.7 I n , , t ■ 

1mQ r beneral venous obstruction. 

lUlo. . • . • . • . . 2.1 

1014 2.5 ) 

1015 2.8 [ Peritonitis. 

1016 3.2 > 

1017 3.6 ; 

1018 4.0 

1019 4.3 

!020 4.7 I Cancerous peritonitis. 

1021 5.1 

1022 5.5 

1023 5.8 

1024 6.2 J 



"When ascitic fluid is allowed to stand as above stated it may become 
faintly opalescent. A delicate clot of fibrin is likely to occur, and there 
is little or no appreciable sediment. Leukocytes, endothelium some- 
times in flakes), red and white blood- corpuscles, granular or fatty cells, 
and crystals of cholesterin may be found at the bottom of the vessel con- 
taining the fluid. If the ascites is due to general venous obstruction, the 
red blood-corpuscles are numerous. The term chylous ascites is applied 
when the ascitic fluid resembles milk, the appearance being due to the 
presence of molecular fat. It is found when the lacteals leak from wounds, 
ulcers, or rupture, or when filarial are present in them. Obstruction of 
the thoracic duct by thrombosis, scars, induration of the mesenteric at- 
tachment to the intestine, and thrombosis of the subclavian vein where 
the thoracic duct enters, also are causes. In the case of the last-men- 
tioned cause the left pleural cavity may likewise contain a milky fluid. 
If the milky appearance of the fluid is due to large and small fat-drops, 
the term adipose ascites is employed. Such fat results from the fatty 
degeneration of cells, and their presence in sufficient abundance is indica- 
tive of a chronic peritonitis or of a tubercular or cancerous peritonitis. 



DISEASES OF THE PERITONEUM. 



969 



The resemblance to milk is further suggested by the formation of a 
creamy layer on the surface when the fluid is allowed to stand. A high 
specific gravity and large percentage of albumin favor the inflammatory 
or neoplastic origin of the fluid, and the sediment then may contain the 
cells of cancer, blood- corpuscles, endothelium, and fat. 

Symptoms. — The immediate effect of ascites is the production of 
pressure upon the abdominal wall and its contents. Such pressure usu- 
ally takes place gradually, but may be of rapid progress. As the abdo- 
men becomes distended there is a sensation of fulness in it which may at 
first be attributed to fat, but soon increases to one of weight and event- 
ually of pressure. The patient moves about with difficulty. He may be 
obliged to remain upright or in the supine position. The displacement 
of the heart upward is likely to produce palpitation. The expansion 
of the lungs is prevented, and respiration becomes frequent and dif- 
ficult. Vomiting and constipation often occur. The urine is scanty, 
high-colored, concentrated, and usually contains a brick-dust sediment. 
These physical characteristics, in addition to a trace of albumin and the 
presence of occasional red blood- corpuscles, are indicative of a chronic 
passive congestion of the kidneys. On physical examination the swell- 
ing of the abdomen corresponds to the duration and degree of the dis- 
tention, and presents a striking picture if the patient is emaciated. In 
the dorsal position the abdomen is likely to bulge in the flanks. In the 
upright position it is prominent towards the front. When the distention 
is extreme the belly is rounded, and the navel may protrude or be ob- 
literated. The skin is dry, smooth, shining, and scarred as in pregnancy. 
The veins in the abdominal wall, especially in the groins, the flanks, and 
over the lower costal cartilages, are distended and prominent, and, if 
cirrhosis is the cause, may radiate outward from the navel. The results 
of percussion vary in accordance with the position of the patient and 
the distention and mobility of the intestines. If the patient is on his 
back, and the stomach and intestines are distended with gas, the epi- 
gastrium is resonant and separated from the lower abdomen by a curved 
line of dulness concave upward. When the patient turns to the side, 
dulness is found over the dependent parts of the abdomen, and resonance 
in that flank which is uppermost. 

If the intestines contain no gas, or are adherent to the abdominal 
wall, or the mesentery is so short, or the quantity of fluid so large, that 
they are prevented from floating to the surface, the dulness is no longer 
characteristic ; but the resonance of the intestines may be found in the 
lower abdomen or in the flanks, in either of which places it may remain 
even if the patient changes his position. Fluctuation is usually present, 
being especially apparent near the border-line between dulness and reso- 
nance, and the wave is often to be seen when the abdominal walls are 
moderately tense. If the latter are excessively fat or (edematous, a su- 
perficial wave may be transmitted, not due to fluctuation of the ascitic 



970 



DISEASES OF THE DIGESTIVE APPARATUS. 



fluid, and should be controlled by the application of pressure between 
the palpating fingers by means of some solid object. There may be no 
fluctuation if the tension of the abdominal wall is either extreme or very 
slight. 

Although the transudation of fluid is usually progressive and the 
ascites persists, there are frequent temporary variations in the quantity 
of fluid present. A period of relief to the symptoms of pressure may 
thus arise, to be soon followed by increased discomfort. The free escape 
of the contents of the stomach and bowels also produces temporary ease. 
More permanent freedom takes place from the absorption of the fluid in 
hepatic ascites, which may occur when there is distention of the smaller 
veins uniting the radicles of the portal vein with those of the peripheral 
venous system. More rarely the ascitic fluid has been discharged into 
the rectum or through the navel. Such relief is usually but temporary, 
since the cause of the ascites is likely to be permanent, and, as a rule, 
steadily increases in severity. 

Diagnosis.— The discovery that the enlargement of the abdomen is 
due to the presence of free fluid is essential for the diagnosis of ascites. 
It is also necessary to determine that this fluid is of non-inflammatory 
origin. The existence of fluid is decided by dulness on percussion and 
by the presence of fluctuation. That the fluid is free is indicated by 
a shifting of the dull fluctuating region with a change in the position of 
the body. Various conditions associated with the presence of more or 
less fluid have been mistaken for ascites. This is especially true in the 
case of fluid contained in large cavities, as the unilocular cystoma of the 
ovary, the parovarian cyst, the fibro-cyst of the uterus, dropsy of the 
amnion, the distended bladder, and the dilated stomach or intestine. It 
is also to be recognized that cysts and ascites may coexist. In such a case 
either the free fluid or the encysted fluid is likely largely to prevail. The 
sex of the patient will exclude some of these conditions. If the abdominal 
wall and that of the cyst are not especially tense, the displacement of the 
intestines is possible when the position of the patient is changed. It may 
be difficult to determine whether the fluid is free or encysted. Commonly 
in the dorsal position the upper line of dulness is concave downward in 
case of ascites and convex upward in case of cyst. On vaginal exami- 
nation the uterus is more freely movable in ascites than in the case of a 
pelvic tumor, and the posterior wall of the vagina is pushed forward by 
the ascitic fluid, which usually fluctuates when the abdominal wall is 
palpated. The absence of elongation of the uterine canal, as shown by 
exploration with the sound, will ordinarily eliminate the uterine fibro- 
cyst. The uterine cavity is also lengthened when dropsy of the amnion 
is present, and a possibility of pregnancy, followed by recurring bloody 
or watery discharges from the vagina, may lead to the diagnosis of this 
condition. Pregnancy has also been mistaken for ascites, but the history 
of the case and the auscultation of the abdomen will suffice to make the 



DISEASES OF THE PERITONEUM. 



971 



diagnosis clear. The distended bladder is easily excluded by the passage 
of a catheter. For dilatation of the stomach to be mistaken for ascites 
the former must be extreme, the lower border of the stomach lying at the 
symphysis. The history of the case, the increase of the abdominal disten- 
tion from above downward, and the use of the stomach-tube will serve for 
the diagnosis of dilated stomach. Litten states that extreme abdominal 
enlargement, dulness with change of position, and fluctuation were present 
in dilatation of the ileum in consequence of stricture. If there was no 
evidence in such a case of a possible cause of ascites, visible peristalsis, 
borborygmi, and perhaps aspiration, would aid in the diagnosis. 

Free fluid in the distended abdomen may be of inflammatory origin, 
due to chronic] peritonitis or to tubercular or cancerous peritonitis as 
well as to ascites. In the last there is no elevation of temperature. In 
the former pain and fever are more likely to occur. In tubercular or 
cancerous peritonitis tubercles or cancer may be found elsewhere, and 
the examination of the omentum, mesentery, and parietal peritoneum, 
including that of the pelvis, may disclose thickenings, perhaps nodular 
masses. The diagnosis of ascites is favored by the existence of symptoms 
of obstructive disease in the liver, heart or lungs, and kidneys. 

The diagnosis is aided by the examination of the aspirated fluid. The 
characteristics of ascitic fluid have been already described. Typical 
ovarian fluid is yellow, somewhat opaque, viscid, of a specific gravity of 
1018 to 1055, and contains a larger quantity of albumin. There is no for- 
mation of a clot on exposure to the air, and the sediment contains cylin- 
drical or globular epithelium, often in a condition of hyaline or fatty 
degeneration. The fluid from the parovarian cyst is pale, watery, of a 
specific gravity of 1005, and has merely a trace of albumin. In the fluid 
from the uterine fibro-cyst clotted fibrin appears in considerable quantity 
after exposure to the air. Peritonitic fluid usually has a specific gravity 
above 1014, contains more than two and five-tenths per cent, of albumin, 
and may also contain a considerable quantity of fibrinogenous material. 
In cancerous peritonitis cells resembling endothelium may be found, but 
their cancerous nature is at times to be recognized, according to Quincke, 
by the presence of glycogen, which becomes brown on the addition of 
dilute solutions of iodine. The physical examination of the abdomen 
after the removal of the greater part of the fluid often makes the diag- 
nosis clear by permitting the recognition of an atrophied liver and an 
enlarged spleen, or of an abdominal or a pelvic tumor. 

Prognosis. — Ascites is always a symptom of serious import, from the 
usually incurable nature of the disease in which it occurs. The greater 
the quantity of fluid, the more rapid its accumulation, and the earlier its 
return after being withdrawn, the worse the prognosis. On the other 
hand, recovery from dropsy has taken place. Small benign tumors have 
been the cause of ascites, and the removal of these has effected a cure. 
Life has been prolonged for years during which repeated removal of the 



972 



DISEASES OF THE DIGESTIVE APPARATUS. 



fluid has taken place, — in the case reported by Lecanu more than eight 
hundred times. The necessity for the removal of the fluid has not rarely 
proved a new source of danger, since fatal intra-peritoneal hemorrhage 
has resulted from puncture of arteries in the abdominal wall, and a fatal 
peritonitis has been caused by the use of unclean trocars. 

Treatment. — In ascites, as in other forms of dropsies, diuretics and 
sudorifics are often useful in getting rid of the dropsical effusion, but, 
owing to the excessive congestion of the kidneys due to the obstruction of 
the portal vein, diuretics very commonly fail to act satisfactorily, whilst 
purgatives are not only certain in their action, but by relieving the exces- 
sive congestion of the whole alimentary tract tend to improve digestion, 
provided they are not given in such form or dose as to cause irritation 
of the gastro-intestinal mucous membrane. In the selection of the pur- 
gative the choice lies between elaterium, compound jalap powder, and 
salines. Instead, however, of confining the patient to one of these purga- 
tives, it is better to use all in turn. One-eighth grain each of elaterium 
and extract of belladonna may be given every six hours, or Epsom salt, 
two drachms, may be given in concentrated solution. 

Whenever the collection of fluid in the abdomen interferes with the 
respiration, and cannot be controlled by purgatives, paracentesis abdomi- 
nalis should be performed, although it is almost invariably followed by the 
rapid accumulation of the fluid. Antiseptic precaution should be abso- 
lute ; the trocar should be disinfected immediately before use. Unless 
in cases of extreme weakness, the patient should be tapped in a sitting 
posture, the trocar being thrust into the abdomen half-way between the 
navel and the pubes and through the linea alba ; hard pressure should 
be exerted upon the whole abdomen by a properly prepared many-tailed 
bandage applied before the beginning of the operation and continually 
drawn on during the flowing of the fluid. After the operation the punc- 
ture should be covered with a piece of rubber plaster, and over this 
antiseptic absorbent cotton, whilst the abdomen should be tightly band- 
aged so as to support the abdominal vessels, which have a tendency to 
become extremely relaxed upon the withdrawal of the support they have 
been receiving from the fluid about them. From six to twelve or even 
more quarts of fluid may be drawn at a single tapping. Trickling of the 
fluid through the aperture after the operation will usually do no harm if 
the liquid be absorbed immediately in the dressing and the skin be well 
protected by the free use of zinc ointment : rarely a circumvoluted suture 
is necessary. In feeble cases digitalis and strychnine should be given 
before the operation, to prevent possible syncope. 

INFLAMMATION OF THE PERITONEUM. PERITONITIS. 

It is especially important for the physician to discriminate between 
acute and chronic peritonitis, since the appropriate treatment of the 
former may prevent the chronic variety, and the early recognition of 



DISEASES OF THE PERITONEUM. 



973 



this form may lead to the adoption of measures productive of speedy 
cure and preventive of prolonged invalidism. Although there is often 
no sharply denned line of division between acute and chronic perito- 
nitis, the one being continued into the other, there are cases which are 
chronic from the outset and which require separate consideration, since 
they are not merely the terminal stage of an acute process. 

ACUTE PERITONITIS. 

Etiology. — Peritonitis occurs equally often in either sex and at all 
times of life, even in the foetus. A distinction is drawn between primary 
and secondary varieties of peritonitis according as the inflammation is 
limited to the peritoneum or is associated with or dependent upon dis- 
ease of parts covered by the peritoneum. Primary peritonitis is also 
sometimes called idiopathic or spontaneous. It has been called rheu- 
matic when a primary peritonitis has developed suddenly after exposure 
to cold, or when, as sometimes occurs, the peritonitis develops during the 
course of acute articular rheumatism. 

In accordance with the prevailing view that inflammations are due to 
the action of irritants and that such irritants are often of bacterial nature 
or origin, a distinction is drawn between simple and septic or infectious 
varieties of peritonitis. Simple peritonitis represents the results of trau- 
matism alone, as from falls, blows, wounds, and aseptic operations, the 
rupture of an ovarian cyst, or the twisting of the pedicle of a peduncu- 
late, especially pelvic, tumor. 

Septic peritonitis results from the association of the above causes, es- 
pecially traumatism and surgical operations, as well as of those to be later 
mentioned, with the introduction of bacteria. Such bacteria may vary in 
kind. Some of them, as shown by experiment, when introduced into the 
healthy peritoneal cavity produce no disturbances ; they are absorbed, 
their growth is checked, or they are destroyed. If the peritoneum is 
abnormal in consequence of traumatism or the presence of chemical 
agents, perhaps derived from the growth of bacteria, or if faeces and 
blood-clots are present in which the growth of bacteria is favored, or if 
the absorbing powers of the peritoneum are interfered with by pre-exist- 
ing disease, as ascites, heart disease, and fibrous hepatitis, septic peri- 
tonitis follows the admission of the bacteria. These may directly enter 
the peritoneal cavity through open Fallopian tubes. They may also pass 
through the peritoneum from parts communicating with the surfaces of 
the body, as the gastro-intestinal canal, the biliary tract, the pancreas, 
the genito-urinary apparatus, the abdominal wall, and the lung by way 
of the diaphragm. The occurrence of a septic peritonitis without ap- 
parent local cause in diphtheria, erysipelas, acute articular rheumatism, 
pneumonia, and cerebro-spinal meningitis is attributable to the transfer 
of bacteria through the blood and lymph from remote parts of the body 
to the peritoneum. 



974 



DISEASES OE THE DIGESTIVE APPARATUS. 



An appreciation of the local causes of peritonitis is of the greatest 
importance, since the resulting inflammation is usually limited for a while 
to the place of its origin, although showing an early and sometimes im- 
mediate tendency to become general. Such local causes are traumatic or 
pathological processes in the gastro-intestinal and biliary tracts, the pan- 
creas, spleen, and genito-urinary apparatus. Pathological processes in 
the blood-vessels and lymphatics of the abdomen and in neighboring- 
parts, as the thoracic organs, the spine, and the pelvic bones, are also 
to be included. It is probable that the development of a peritonitis 
in the various infectious diseases is connected with a local cause which 
eludes recognition, — for example, embolism or hemorrhage. 

Exclusive of injuries and operations, the most frequent local causes of 
peritonitis are to be found in affections of the gastro-intestinal tract, the 
genitals of the female, and the gall-bladder. 

Morbid Anatomy. — The lesions of acute peritonitis are usually cir- 
cumscribed at the outset, but tend to become diffused. A distinction is 
thus drawn between a local and a general peritonitis, the lesions being the 
same, differing only in extent. At the outset the peritoneum is slightly 
opaque, its surface dull, its blood-vessels injected, and minute hemor- 
rhages are present in the subperitoneal fibrous tissue. Soft gray or yellow 
clotted fibrin appears on the surface, forming false membranes varying in 
thickness and opacity, or adhesions as delicate threads, strings, or bands. 
A liquid exudation likewise appears, at first thin, watery, and slightly 
opaque, but later thick, yellow, and purulent. According to the predom- 
inance of one or another characteristic of the exudation the peritonitis 
is spoken of as fibrinous, serous, or purulent. Eed blood-corpuscles are 
also present in the exudation, sometimes in such abundance as to pro- 
duce a red color. This hemorrhagic peritonitis occurs chiefly in scor- 
butic or purpuric cases or in tubercular and cancerous peritonitis. 
When acute inflammation of the peritoneum results from the rupture 
of an ovarian cystoma, vascularized fibrous adhesions are eventually 
formed between the surfaces of the peritoneum and of the tumor. The 
gelatinous material secreted from the wall of the ruptured cyst may 
become traversed, enmeshed, and encapsulated by the adhesions, a mass 
thus being formed resembling a myxoma. To this variety of peritonitis 
Werth has applied the term peritoneal pseudo-myxoma. Bacteria, espe- 
cially the streptococcus, the staphylococcus, the colon bacillus, and the 
pneumococcus, are found in the exudation and upon the inflamed peri- 
toneum in septic peritonitis. The streptococcus is especially frequent 
in puerperal peritonitis. The quantity of liquid exudation which may 
be present varies from a few ounces to several quarts. When the 
exudation is both fibrinous and liquid, collections of the fluid are often 
found enclosed within a mesh-work of fibrin, in which the spaces may 
sometimes be of considerable size. 

The stomach and intestines are distended with gas, often to an extreme 



DISEASES OF THE PERITONEUM. 



975 



degree ; their walls are (edematous, and the peritoneum is easily torn and 
stripped from the muscular coat. In peritonitis from perforation of the 
stomach or intestine, gas is likely to be present in the peritoneal cavity, 
and the exudation is thin, opaque, of a greenish tint, and of a faecal odor. 
Such an odor may also be present when there is no visible perforation of 
the intestine, especially if the exudation is circumscribed in the vicinity 
of the large intestine. 

Symptoms. — Abdominal pain is usually the first symptom of acute 
peritonitis. It is sometimes slight at the outset, gradually increasing in 
severity, when it is apt to be attributed to indigestion, or it may be 
sudden and intense, as in peritonitis from perforation j in puerperal 
cases it is not, as a rule, severe. It may be preceded by a brief period 
of slight malaise, or may follow a chill. The pain is cutting, piercing, 
tearing, or griping, and is likely to be aggravated on motion of the pa- 
tient, even from coughing, vomiting, or defecation, perhaps from draw- 
ing a long breath. The dorsal decubitus is usually maintained. The 
knees are often drawn up, and the pressure of even the bedclothes may 
be burdensome. 

The pain is often localized at first, or it may be present throughout 
the abdomen. It is frequently referred to the vicinity of the navel, 
to the epigastrium, or to other regions which may be remote from its 
place of origin. The source is more correctly determined by the seat of 
tenderness than by the painful region. The localized tenderness and 
pain soon become generalized, the suffering being greatest where the 
normal peritoneum is being invaded, and diminishing as the exudation 
is formed. 

Vomiting is also an early symptom, perhaps the first, but usually 
quickly follows the incipient pain, and is likely to continue throughout 
the disease. It is so readily produced by food or drink, even in small 
quantities, that the patient often refuses them. At first the contents of 
the stomach are expelled, then bile is vomited, and in the course of a few 
days the contents of the small intestine, often having the odor and ap- 
pearance of thin yellow fseces, regurgitate through the incompetent py- 
lorus and are vomited. At times, and especially towards the end of life, 
the vomit is of a dark-brown color, perhaps flocculent, resembling partly 
digested blood. Nausea and belching also occur. Hiccough may take 
place when the peritoneal covering of the diaphragm is inflamed, and 
often proves a most distressing symptom by causing wakefulness and pro- 
longing pain. 

The abdominal walls in the region of incipient pain and tenderness 
are usually found tense, perhaps retracted. The abdomen soon becomes 
swollen, however, from the increasing formation and retention of gas 
within the bowel, its expulsion being prevented by a paresis or paralysis 
of the muscular coat. With the increasing distention of the bowel the 
abdomen grows larger, and may be enormous if the abdominal wall is 



976 



DISEASES OF THE DIGESTIVE APPARATUS. 



thin and the muscles are stretched and flaccid, as in puerperal peritonitis. 
In men with powerful abdominal muscles the abdominal distention may 
be inconsiderable. If intestinal perforation is the cause of the peritonitis, 
gas in the peritoneal cavity usually aids in producing the abdominal en- 
largement. With the persistence of the peritonitis, and especially with 
freedom of action of the bowels, the abdomen is likely to become less 
distended. 

Fever is next in importance to the previously mentioned symptoms 
of peritonitis. The temperature usually ranges from 100° to 103° F., the 
evening temperature being, as a rule, higher than that observed in the 
morning. If the patient is collapsed, the temperature is often subnormal, 
and it has been found as high as 110° F. shortly before death. The 
temperature may be lower than 100° F., yet the peritonitis be general, 
critical, or fatal. In circumscribed peritonitis the pulse may be but little 
altered in strength or frequency. The severer the peritonitis and the 
longer its duration, the weaker and more frequent the pulse, which often 
rises to 130 or 140 and is counted with difficulty or becomes imper- 
ceptible. 

The respiration is rapid, superficial, and painful. In extreme cases 
the inspirations may be thirty or forty in a minute, such frequency being 
in part explained by the displacement upward of the diaphragm, with the 
resulting retraction of the lungs and dislocation of the heart, a^d in part 
by the weakening of the heart by the existing toxaemia. It is painful from 
the irritation of the nerves in the inflamed peritoneum by the respirator 
movements of the diaphragm and of the anterior wall of the abdomen. 

The tongue soon becomes covered with a thin, white coat. Later it is 
dry, brown, and cracked or fissured. There is no appetite. Both food 
and drink are taken only in small quantities, and are often quickly 
regurgitated, or the accumulated contents of the stomach, largely undi- 
gested, are vomited at intervals of hours. The bowels are usually con- 
stipated at the outset, although a few loose movements may take place, 
while numerous loose dejections may occur in the later stages, and are 
the rule in puerperal peritonitis. Micturition is frequent and painful 
when the peritoneal coat of the bladder is inflamed, although reten- 
tion of urine often occurs in peritonitis, largely from the effect of the 
opiates administered. The urine is diminished in quantity, dark, acid, 
and of high specific gravity. It usually contains a trace of albumin, 
and indican is present in large quantity. The latter is best recognized, 
according to Jaffe, by adding two or three drops of a fresh concentrated 
solution of chlorinated lime to equal parts of urine and hydrochloric 
acid. The mixture when shaken becomes of a dark-blue or bluish-black 
color. 

The mental condition of the patient is often unaffected throughout 
the disease, although there may be mild delirium or stupor. Symptoms 
of extreme collapse usually occur early in peritonitis from perforation. 



DISEASES OF THE PERITONEUM. 



977 



The eyes become sunken, the nose pinched, the skin cold and moist, the 
voice husky, and the pulse rapid and weak. Such symptoms, less ex- 
treme and more gradual, occur later in the disease, when the exudation 
of a circumscribed peritonitis escapes into the general peritoneal cavity. 
The expression of the patient is one of suffering and anxiety, and the 
physical examination of the abdomen is dreaded through fear of an 
increase of the pain. At the outset the abdomen is not enlarged, and 
may be retracted, but with the accumulation of gas and exudation the 
abdomen may become so swollen as to project considerably above the 
thorax. The overlying skin is smooth and shining, and the outlines of 
coils of distended intestine are at times to be seen. The heart is dis- 
placed upward and outward, and the apex may be found in the fourth 
intercostal space, and the border of cardiac dulness at the third rib. 
The upper border of hepatic dulness at times is found at the third rib, 
and the area of hepatic dulness may be greatly diminished by a rotation 
of the liver on its transverse axis. 

Palpation of the abdominal wall shows that its muscles are tense and 
resistant in the early stage of the peritonitis, but the resistance dimin- 
ishes with the progress of the disease, and is least when an abundant 
liquid exudation is present. Fluctuation may then be found, especially 
at the dependent portion of the abdomen, and the presence of perito- 
nitic fluid may be simulated if there is much liquid in the intestines, or 
if the subcutaneous tissue contains abundant fat or fluid. During the 
early stages of a fibrinous exudation friction sometimes is felt. 

The distended abdomen is tympanitic until the exudation becomes 
considerable. Eesonance is generally due to the presence of gas in the 
intestines, but also results from gas in the peritoneal cavity when peri- 
tonitis is caused by perforation of the stomach or intestines. Undue im- 
portance has been attached to the disappearance of hepatic dulness as a 
sign of such perforation. Eesonance may replace hepatic dulness, how- 
ever, when a portion of intestine distended with gas lies between the liver 
and the abdominal wall, also when the liver is pushed upward and rotated 
on its transverse axis in extreme enlargement of the abdomen from ac- 
cumulation of gas in the intestines. Even if gas is present in the perito- 
neal cavity, it is prevented from accumulating between the liver and 
the diaphragm where there is obliteration of this space by adhesions. 
It is therefore important to know the pre-existing limitations of hepatic 
dulness before concluding that the existing condition is pathological. 
With the appearance of the liquid exudation, resonance is usually re- 
placed by dulness, which begins in circumscribed peritonitis in that part 
of the abdomen where the inflammation originates. In general perito- 
nitis the dulness is first found in the dependent portions of the abdomen. 
In the former the region of dulness remains fixed when the position of 
the body is changed, while in general peritonitis the dull area shifts as 
the fluid gravitates. A liquid exudation may not give rise to dulness 

02 



978 



DISEASES OE THE DIGESTIVE APPARATUS. 



on percussion if it is separated from the abdominal wall by coils of in- 
testines distended with gas. On auscultation crepitation may be recog- 
nized where friction is to be felt. The former may also be heard when 
the latter is absent, and may be produced by the rubbing of opposed 
peritoneal surfaces in respiration or peristalsis. Gurgling may be heard 
with and without the stethoscope when the movements of the bowels are 
active. 

The progress and results of a localized peritonitis are best considered 
in connection with the diseases which it complicates, and the clinical 
picture often is so characteristic that especial terms in nosology are ap- 
plied when certain localities are affected, as subphrenic abscess, peri- 
typhlitis, pelvic abscess. If early death does not occur in the course of 
an acute general peritonitis, a long period of invalidism is likely to ensue. 
The fever persists, and may follow an irregular, atypical course. Lack 
of appetite and digestive disturbances are conspicuous. The abdominal 
enlargement lessens with the free escape of the intestinal contents. Pus 
may escape by the establishment of fistulse opening externally, but the 
tendency is towards progressive wasting and enfeeblement. If the patient 
survives, the liquid and fibrinous exudations disappear, and are replaced 
by fibrous thickenings of the peritoneum, forming patches and plates or 
bands and cords, producing atrophy, disturbance of function, persistent 
suffering, perhaps death. The liver, spleen, and ovaries are especially 
liable to be atrophied. Severe disturbance of the function of the stomach 
may result from the thickening of the peritoneal coat, while chronic 
obstruction of the intestines may ensue from thickening and adhesions 
of their peritoneum. The formation of gall-stones and their incarceration 
in the gall-bladder are favored by the fibrous thickening of the perito- 
neum covering the latter, and chronic or recurring attacks of appendicitis 
frequently result from the persistence of the products of a peritonitis in 
the right iliac fossa. Similar thickenings and adhesions in the pelvis are 
often sources of organic and functional disease in women, being produc- 
tive of sterility and ectopic gestation, and interfering with intra-uterine 
gestation and childbirth. 

Diagnosis. — The diagnosis of acute peritonitis rests upon the occur- 
rence of abdominal pain and tenderness, soon followed by vomiting, 
fever, and abdominal distention, which is at first tympanitic, but later 
dull on percussion. The diagnosis is doubtful in the early stage alone, 
when colic and vomiting are the only significant symptoms. Gastro- 
intestinal colic is commonly relieved by pressure, and often has an ob- 
vious cause. Biliary colic is more sharply defined, is associated with 
less localized tenderness, and a distended gall-bladder may be felt. The 
usual absence of fever and the frequent eventual appearance of jaundice 
may be of avail. Eenal colic is sharply confined to the region of the 
kidney or to the course of the ureter, and the examination of the urine 
is likely to indicate the nature of the pain by disclosing sand, gravel, 



DISEASES OF THE PERITONEUM. 



979 



concretions, or blood. Uterine colic is afebrile, intermittent, and gener- 
ally associated with menstruation, pregnancy, or a tumor. The pain 
and tumor from salpingitis remain localized, and are unaccompanied by 
the vomiting and abdominal distention of general peritonitis, although 
fever may be present. In acute intestinal obstruction the pain, in its 
onset, character, and severity, may closely resemble that of acute peri- 
tonitis. If the large intestine is obstructed, there is no excess of indi- 
can in the urine, as in acute general peritonitis and in obstruction of 
the small intestine. It may be impossible, however, to make a satis- 
factory differential diagnosis, and an exploratory laparotomy has fre- 
quently been performed for this purpose. Most important for the 
diagnosis is the recognition of a probable cause for the peritonitis. 

Earely the pain may be so slight as to be insignificant, and the diagno- 
sis of peritonitis then will depend upon the recognition of the exudation. 
It may be mentioned that a pregnant uterus, an ovarian tumor, an echi- 
nococcus cyst, and a full bladder have each been mistaken for peritonitic 
exudation. Auscultation, catheterization, and perhaps aspiration and 
examination of the fluid will serve to eliminate these possibilities. 

Since most cases of general peritonitis are circumscribed at the outset, 
and since many cases of circumscribed peritonitis remain localized, and 
some are more likely to spread than others, it is important to determine 
if the peritonitis is spreading or likely to become general. It is, there- 
fore, of the utmost practical importance to determine the cause of the 
peritonitis. For this purpose a thorough knowledge of the etiology of 
peritonitis, a complete history of the patient's antecedents and symp- 
toms, and an accurate knowledge of the seat of original tenderness are 
essential. 

The spreading of a peritonitis is indicated by the persistence or in- 
crease of the vomiting, tympany, elevated temperature, and rapid and 
weak pulse, in addition to enlargement of the tender and painful area 
and increase in the quantity of exudation, perhaps discoverable by a vag- 
inal or rectal examination. Undue importance should not be attached 
to variations in temperature, since generalization of the peritonitis may 
occur with little or no elevation of temperature. 

Prognosis. — Acute general peritonitis usually proves fatal within the 
first ten days, especially within the first week. If the patient's life is 
prolonged beyond this period, the disease tends to become chronic, and 
then often ends fatally in the course of weeks or months, the condition 
being essentially one of septicemia. 

The prognosis of the case in hand especially depends upon the cause 
of the peritonitis, the quality of the exudation, and the previous con- 
dition of the patient. In general the cessation of vomiting and the return 
of defecation are favorable signs. A lower temperature combined with a 
steady pulse and other favorable symptoms is encouraging, but a normal 
or subnormal temperature may be present in cases of the utmost gravity. 



980 



DISEASES OF THE DIGESTIVE APPARATUS. 



It is also to be remembered that, especially after the first week, patients 
in whom improvement is apparently taking place may suddenly die from 
cardiac paralysis. Peritonitis from perforation of the stomach and of 
the free portion of the intestine into the normal peritoneal cavity is 
rarely recovered from. Puerperal peritonitis and that following instru- 
mental abortion are often fatal, especially when there is abundant exu- 
dation of a more purulent than serous or fibrinous character. If the 
exudation is thin, acrid, and of an offensive odor, the patient almost 
invariably dies. If acute peritonitis occurs in a person suffering from 
serious acute or chronic disease, the prognosis is correspondingly grave. 

The prognosis of circumscribed peritonitis is generally favorable, and 
medical treatment may suffice for the cure. The prognosis of spreading 
peritonitis is uncertain until the employment of surgical measures, after 
which the outlook may remain doubtful for a short time, or may imme- 
diately improve, and recovery be almost certain. 

Treatment. —In all forms and degrees of peritonitis it is essential 
that the patient be kept absolutely quiet on the back in bed, and that 
every precaution be used to prevent movements of the abdomen. If 
there be any difficulty whatever in passing urine, catheterization should 
be at once practised. In sthenic cases the food should be restricted to 
animal broths and milk (preferably predigested), so as to reduce as far 
as possible the fsecal residuum. In asthenic cases beef essence and con- 
centrated broths may be used ; but solid food should never be given. 

External applications to the abdomen may be used in all forms of the 
disease. In most cases ice-poultices or ice-bags are both agreeable and 
effective, but sometimes hot applications are more grateful and should be 
used. Yery frequently cold applications are better borne and do better 
in the early stages of the disease, whilst moist heat is to be preferred at 
the later period. Counter-irritants have very little control over a pro- 
nounced peritonitis ; the only form which is effective is the blister, but 
to effect anything in a wide-spread, general peritonitis this must be so 
large that it interferes with other local applications and is of itself de- 
pressing to the vitality. On the other hand, in a circumscribed peri- 
tonitis, after the severity of the attack has been lessened by local blood- 
letting, blisters may be distinctly advantageous. 

The active medical treatment of acute peritonitis varies extremely 
with the cause and the character of the attack. In sthenic medical 
peritonitis, beginning as it usually does in a circumscribed centre, the 
taking of blood from the arm, or, as I have always done it, by free 
leeching, will influence the disease very markedly. I have repeatedly 
seen it arrest an attack in which the symptoms were so violent and the 
cause so evident that there could be no doubt as to the nature of the 
disease. It is necessary to take enough blood to afford complete relief 
of pain or to affect the pulse. If leeches be used, not less than from 
seventy-five to one hundred American leeches or from fifteen to twenty 



DISEASES OF THE PERITONEUM. 



981 



foreign leeches should be applied, and often free after- bleeding from the 
leech-bites should be encouraged. In septic peritonitis or a peritonitis 
following perforation in typhoid fever such leeching would almost cer- 
tainly kill the patient. 

The question of the use of purgatives in peritonitis is vital, but diffi- 
cult to answer.. Their use or disuse should be in accordance with the 
nature of the peritonitis and the character of its cause. If the peritonitis 
be due to irritant food or other material in the intestinal tract, or if it be 
accompanied by the presence of faecal masses in the intestines, there can 
be no doubt as to the value of saline purgatives. Free serous purgation, 
further, must greatly empty the intestinal vessels and probably relieve 
congestion and reduce oedema if it exists, and also lessen the chances of 
serous exudation. On the other hand, the increased peristalsis which 
the purgative produces must tend to increase peritoneal irritation, and 
the argument which has been brought forward that purgation does good 
by preventing adhesions seems to show, if it be founded on fact, that 
purgatives are dangerous remedies, because if they increase peristalsis 
enough to tear adhesions they must greatly irritate the inflamed mem- 
brane. It is evident that in a peritonitis depending on perforation j>ur- 
gation is strongly contra-indicated. 

It is sometimes argued that purgatives do good in peritonitis by elim- 
inating ptomaines and other products of the inflammation, but of this no 
proof seems ever to have been afforded. Many laparotomists very highly 
recommend salines after operation, as tending to check peritonitis ; the 
concurrence of surgical opinion is not absolute, and certainly in medical 
peritonitis caution is necessary in their use. In many cases it may be 
judicious to give a single large dose of the saline, and after full action has 
been secured to withdraw the purgative and check peristalsis by opium. 

The opiate treatment of medical peritonitis has been very largely 
practised, and has great value ; the drug not only relieves pain and checks 
vomiting and peristalsis, but seems, in some way not at present under- 
stood, to allay inflammation and to prevent vital exhaustion. The amount 
of opium required is sometimes extraordinarily large. Dr. Alonzo Clark 
is said to have given successfully over seven hundred grains in two days. 
I do not believe such heroic treatment justifiable. I have never given 
over seventy-five grains of opium in a day, and have at least in one 
case seen a fatal narcosis produced. It is essential in the use of such 
doses that the drug be administered in such a way as to secure immediate 
absorption. No solid preparation of opium should be used. The de- 
odorized tincture may be given by the mouth, but at least the alternate 
closes should be morphine sulphate (one-fourth to one-half grain) ad- 
ministered hypodermically. Enough opium must be given to produce 
continuous decided narcotism, but the patient must be carefully watched 
by a competent attendant, and the drug suspended whenever the narcotic 
symptoms become pronounced. 



9S2 



DISEASES OF THE DIGESTIVE APPARATUS. 



In sthenic peritonitis without tendency to the formation of pus I 
believe calomel to be a valuable remedy. It is. however, essential to 
avoid its cathartic effects, and it should therefore be given cautiously in 
small repeated doses (one-sixth of a grain every two hours) during the 
day. The slightest evidence of ptyalism should be the signal for its 
withdrawal 

In septic peritonitis, and in the peritonitis which follows perforation, 
medical treatment is of very little avail. The most that can be done is to 
administer opium freely and to support the general strength. When there 
has been perforation, all food should be withdrawn except teaspoonful 
doses of beef essence every half-hour. 

In the management of peritonitis various symptoms must be judi- 
ciously met. For the allaying of the thirst, which is often excessive, 
small pieces of ice should be given : on no account should the patient be 
allowed to take a large drink of water. The vomiting is usually con- 
trolled by the opiate and the ice. but may require small quantities of 
effervescing draughts. In some cases of excessive vomiting a portion of 
the opium may be given by the rectum. When there is great tympany a 
rectal tube should be passed as high up as possible into the large intestine 
and allowed to remain. Some authorities recommend puncturing the 
distended intestine with a fine trocar : this I have never done. When 
collapse and cardiac failure occur, digitalis and strychnine may be given 
by the mouth, or. better, subcutaneously. and champagne or other alcoholic 
liquors are allowed. When, however, the vital powers so far fail in peri- 
tonitis, death usually occurs : on the other hand, the local irritant influ- 
ence of alcoholic liquors upon the gastro-intestinal tract is capable of 
doing much ill. so that stimulants are rarely of real service. 

The question of operative procedure in acute peritonitis is one of 
great importance. According to Richardson, in advanced general peri- 
tonitis laparotomy and irrigation are so uniformly fatal that it is safer to 
take the slim chances of recovery under purely medical care. Early in 
the disease it is. in my opinion, never justifiable to operate unless the 
cause is of such character as in itself to indicate surgical interference : 
of such nature would be a localized abscess, a removable tumor, or a 
gastric or an intestinal perforation. 

In the treatment of the convalescence from peritonitis the greatest 
care must be exercised to prevent mechanical irritation from without or 
from within, so that all violent exercise must be strenuously interdicted, 
whilst constipation and irregularities of diet are carefully guarded against. 
It is often essential to put on the abdominal bandage. (H. C. W.) 



From my point of view all acute peritonitis of any severity is both 
septic and suppurative to a greater or less extent : leeches, therefore, are 
harmful, and the cathartic effects of calomel are to be avoided. 



DISEASES OE THE PERITONEUM. 



983 



The widely divergent opinions as to the use of purgatives in the 
treatment of acute peritonitis appear to be based largely upon the 
assumption that the diagnosis is plain and that this affection is always 
the same. The most expert diagnostician, however, cannot always 
recognize at the outset the nature of an abdominal affection of which 
pain, tympany, constipation, and fever are the symptoms. In the great 
majority of such cases the symptoms, especially in the male, when of 
obscure or unknown etiology, are due to a peritonitis of intestinal origin, 
the lesion being at or above the caecum. The effect of laxatives is to 
cause the bowels to move, usually with the expulsion of more or less of 
the contents of the large intestine. It seems more rational to empty 
this part of the bowel, in case of need, from the nearest point, namely, 
from the anus, than to irritate the many feet of small intestine above the 
region of faecal accumulation. Such irritation is unquestionably danger- 
ous in peritonitis from perforation of the bowel and in strangulation of 
the intestine, conditions often not to be differentiated in the early stage 
from a harmless grouping of similar symptoms. 

The medical treatment of acute peritonitis, therefore, should consist 
in the adoption of measures tending to localize the inflammation in the 
vicinity of its starting-point. Opium is to be given in such quantity 
only as will relieve pain. All laxatives by the mouth are to be avoided 
as long as there is any possibility of the alimentary canal being the 
source of the peritonitic symptoms. Evacuation of the bowels is de- 
manded, not with the hope of aborting or of curing the disease, but for 
the sake of promoting the expulsion of the intestinal contents, the reten- 
tion of which, especially when gaseous, is often a source of marked dis- 
comfort. If the localized peritonitis persists or the inflammation tends 
to become generalized despite the medical treatment, surgical measures 
alone offer a more promising outlook. (R. H. F.) 

CHRONIC PERITONITIS. 

The possibility of the termination of acute inflammation of the peri- 
toneum in chronic peritonitis has been already mentioned. In such 
cases there is a gradual improvement in the symptoms suggestive of 
a prolonged convalescence from the acute attack, although permanent 
disturbances of the function of the alimentary canal, the liver, and the 
gall-bladder, and of the genito-urinary apparatus of the female, may re- 
main as evidence of the previous disease. Such a chronic peritonitis, 
like the acute attack, is either circumscribed or diffused. An explana- 
tion of the origin of such chronic attacks is to be found in the semi-fluid, 
caseous, or calcified masses of inflammatory exudation due to an acute 
attack and encapsulated by thickened peritoneum or dense adhesions. 
The contents of such circumscribed portions of the peritoneal cavity may 
be discharged through communications established between them and 
the interior of the intestine or the bladder, or may escape externally 



984 



DISEASES OF THE DIGESTIVE APPARATUS. 



through the abdominal wall. The course of the chronic peritonitis thus 
becomes complicated and protracted. 

The rare occurrence of the chronic hemorrhagic peritonitis described 
by Friedreich and caused by repeated abdominal tappings in the treat- 
ment of ascites may be referred to. Layers of a thick granular membrane 
containing numerous nodules of extravasated blood were found adherent 
to the visceral and parietal peritoneum. 

The productive manifestations of a chronic peritonitis may be mani- 
fested by fibrous thickenings and peritoneal adhesions found after death 
in those regions which are most frequently the sites of an acute peri- 
tonitis. In the history of the patients, however, there is frequently no 
recognition of any disturbances which would suggest the possible dis- 
covery of such lesions. This evidence is significant that attacks of peri- 
tonitis may be of sufficient duration to produce permanent alterations, 
yet be productive of such slight disturbance as to be disregarded. 

CHRONIC SEROUS PERITONITIS. CHRONIC GRANULAR 
PERITONITIS. 

Within a few years especial attention has been called to the occur- 
rence of cases of chronic diffuse peritonitis in which large quantities 
of liquid exudation have been found. Such cases had been previously 
confounded with ascites or with tubercular, cancerous, or sarcomatous 
peritonitis. 

Etiology. — That this affection has been called idiopathic or essen- 
tial is sufficiently indicative of the recognized obscurity of its origin. 
Among the exciting or predisposing causes are enumerated injury, ex- 
posure to cold, profuse and protracted diarrhoea, measles, typhoid fever, 
syphilis, and vulvo-vaginal catarrh. What is of greater practical im- 
portance is the fact that girls are predominantly affected after the age 
of three years, and frequently at the beginning of puberty. It is proba- 
ble, as suggested by Henoch, that many of the cases of supposed perito- 
neal tuberculosis with abundant liquid exudation successfully treated by 
laparotomy belong in this series. 

Morbid Anatomy. — The anatomical changes are in general rather 
a matter of inference than of observation. Hirschberg, in a case dying 
from intercurrent disease, found the peritoneum normal except over a 
portion of the colon where it was irregularly thickened. At a laparotomy 
the peritoneum was seen by Henoch to be studded with small nodules 
resembling tubercles. These proved to be composed of fibrous or gran- 
ular tissue, bacilli and giant- cells being absent. Other observers, Welch 
among the first, have noted similar lesions, and the term chronic granular 
peritonitis has been applied to this variety. 

Symptoms. — Progressive distention of the abdomen, often becoming 
extreme, apparently from free fluid, is the characteristic symptom. It 
may be considerable and the patient present no other symptoms. On 



DISEASES OF THE PERITONEUM. 



985 



the other hand, it may be associated with loss of appetite, pallor, and 
wasting. Fever, pain, and tenderness are usually lacking, and the dis- 
comfort, perhaps slight, is attributed to the pressure and weight of the 
liquid exudation. 

Months generally elapse before the abdominal distention becomes con- 
siderable, although at times a few weeks only are necessary. Occasionally 
temporary variations in the size of the abdomen may occur without any 
special modification of the general course of the disease. In certain 
cases a continued diarrhoea or persistent diuresis is associated with the 
absorption of the fluid. 

The physical signs indicating the presence of free fluid are those 
already mentioned in connection with ascites. The fluid may be more 
serons, sero-fibrinous, or sero-purulent, and is richly albuminous. Its 
inflammatory origin is thus indicated, although fibrin or pus- corpuscles 
may be absent. At times, after removal of the fluid by tapping or ab- 
sorption, dense rounded masses have been felt in the abdomen, and in 
certain instances have been found to be circumscribed thickenings of the 
peritoneum of the omentum, mesentery, or intestine. 

Diagnosis. — Since the characteristic sign is excessive free fluid in 
the abdominal cavity, and symptoms are often wanting, it becomes neces- 
sary to differentiate this affection from ascites and tubercular or cancerous 
peritonitis. The age and sex may prove of value in excluding ascites, 
as may the absence of digestive disturbances, jaundice, enlarged spleen, 
clay-colored stools, itching, and hemorrhage. The negative character of 
the symptoms, and the absence of abnormal signs on auscultation of the 
heart and lungs, and of albuminuria, blood, and casts on examination of 
the urine, are of importance in eliminating other sources of ascites. Es- 
pecial importance is to be attached to the specific gravity of the aspirated 
fluid, which is likely to be above 1015, while that of ascites is below this 
point. Tubercular peritonitis is excluded with more difficulty. The 
latter affection sometimes progresses, for a while at all events, with but 
little constitutional disturbance. The macroscopic appearances of the 
lesions as found by Henoch and others may not differ from those present 
in tuberculosis. The enlargement of the abdomen in tubercular peri- 
tonitis, as a rule, progresses more rapidly, and is more likely to be asso- 
ciated with elevation of temperature, pain and tenderness, progressive 
emaciation, and loss of strength. The physical signs of tuberculosis 
elsewhere in the patient, or its presence in other members of the family, 
would favor the diagnosis rather of tubercular peritonitis than that of 
chronic granular or serous peritonitis. Cancerous peritonitis might be 
excluded by the youth of the patient and failing cachexia and tumors. 

Prognosis. — In the light of our present knowledge the prognosis is 
favorable, since recovery usually takes place unless prevented by inter- 
current disease or unsuccessful surgical treatment. Months are generally 
required for the absorption of the fluid. 



986 



DISEASES OF THE DIGESTIVE APPARATUS. 



Treatment. — The diet in chronic peritonitis should be light, easily 
digested, and nutritions. Confinement to bed may or may not be neces- 
sary, but if possible an abundance of out- door life in a hammock or other- 
wise should be secured. Symptoms should be carefully combated as they 
arise : thus, laxatives may be useful if there be constipation, astringents 
if there be diarrhoea. The long- continued administration of minute 
doses of corrosive sublimate (one-fiftieth of a grain) or of potassium 
iodide (one to two grains), or, especially to children, of ferrous iodide, 
is justifiable. Great benefit has been asserted to be produced by various 
local applications, especially the solution of iodine in olive oil (seven 
to thirty grains to the ounce) and mercurial ointment. Pribram strongly 
recommends gentle friction once a day with soft soap (vulgo, "green 
soap") and water, followed by the continuous application of oil-silk or 
thin rubber cloth, and steadily maintained until the skin becomes hard 
and scaly. When there is excessive fluid, tapping has been largely 
practised ; but it is advisable, if the symptoms continue notwithstanding 
treatment, to have laparotomy performed. 

TUMORS OF THE PERITONEUM. 

Tumors grow from the free surface of the peritoneum and from the 
subperitoneal tissue. Among the former are the sarcoma, endothelioma, 
and cancer, which belong to the malignant tumors. The benignant 
cystic, dermoid, and teratoid tumors of the ovary, although lying within 
the peritoneal cavity, do not originate from the peritoneum, while the 
malignant adenoma of the ovary, also lying within the peritoneal cavity, 
may after rupture of the cyst-wall become extended as a secondary 
growth to various portions of the free surface of the peritoneum. The 
tumors which proceed from the subperitoneal tissue, especially of the 
omentum and the mesentery, are often benignant, as the myxoma, fibroma, 
lipoma, hemangioma, chylangioma, and entero-cysts, but may be ma- 
lignant, as the sarcoma and cancer. The malignant tumors are more 
frequently primary in the abdominal viscera, their growth being con- 
tinued into the subperitoneal tissue. Some of these tumors are of purely 
pathological interest ; others, in virtue of their size and resulting me- 
chanical disturbances, demand surgical treatment. Those which are of 
especial importance to the physician are the malignant tumors of the 
peritoneum, which are conveniently described as cancer, although the 
structure may prove to be that of a sarcoma, endothelioma, or malignant 
adenoma. 

CANCER OF THE PERITONEUM. 

Etiology. — Cancer of the peritoneum is sometimes primary, but 
usually secondary, proceeding from parts covered by peritoneum. In 
the latter case the primary growth is to be found in the alimentary canal, 
especially in the stomach, in the large intestine (caecum, sigmoid flexure, 
and rectum), and in the oesophagus. Cancer of the peritoneum may be 



DISEASES OF THE PERITONEUM. 



987 



secondary to cancer of the ovary, uterus, kidney, pancreas, liver, gall- 
bladder, or suprarenal capsule. It may be secondary to primary disease 
in more remote parts of the body extended through the blood-vessels or 
the lymphatic apparatus, especially from the retroperitoneal glands. It 
usually occurs after middle life, and its etiology is as obscure as that of 
cancer elsewhere. 

Morbid Anatomy. — All the varieties of cancer conveniently de- 
scribed as scirrhous, hard or fibrous, encephaloid, soft or medullary, pig- 
mented or melanotic, colloid or hyaline, may be found, the last most fre- 
quently. The tumors may be directly continued to the peritoneum, or 
there may be several centres of growth, — so-called metastatic tumors. 
Single or multiple growths thus arise, the latter 'sometimes so minute 
as to resemble miliary tubercles. All tend to enlarge and to become 
fused, resulting in the presence of masses which are sometimes enormous. 
The omentum and the mesentery are especially liable to be the seats of 
large tumors. Nodules of considerable size may be found early in the 
progress of the disease in Douglas's fossa. Cancer of the peritoneum is 
frequently associated with evidences of ascites or of peritonitis. The 
ascitic fluid is sometimes milky, from the presence of abundant fattily de- 
generated cells, — adipose ascites. The peritonitic liquid exudation has a 
high specific gravity, above 1016, in virtue of the abundant albumin, 
and is often hemorrhagic. Fibrous thickenings and adhesions, the latter 
sometimes producing obliteration of portions of the peritoneal cavity, 
are often present. 

Symptoms. — There may be no symptoms associated with cancer of the 
peritoneum, the condition being first recognized at an autopsy. If symp- 
toms are present, they are usually attributable to the associated ascites 
or peritonitis, or are dependent upon disturbances in the function of the 
organ in which the disease arises. The ascitic symptoms are conspicu- 
ously mechanical, especially the disturbed respiration and circulation. 
The peritonitic symptoms also are partly mechanical, but in addition 
there are likely to be pain, usually moderate, and fever, as a rule slight 
and irregular. Colic, constipation, and meteorism are not infrequent 
results of obstruction to the function of the bowels by the growth of the 
cancer. Symptoms of sudden, severe, perhaps fatal, anaemia may occur 
in consequence of rupture of large and thin- walled blood-vessels in ex- 
cessively vascular varieties of cancer, and an acute peritonitis, either cir- 
cumscribed or diffused, in the latter case rapidly fatal, may result from 
X^erforation of the intestine infiltrated with cancer. As the disease pro- 
gresses, pallor, wasting, and debility are likely to occur. On physical 
examination tumors are often felt, although there may be so much fluid 
as to prevent their recognition until the liquid has been removed. In 
repeated instances a growth of the cancer has taken place along the 
track of the trocar used in withdrawal of the fluid. Eectal or vaginal 
palpation may disclose a tumor in Douglas's fossa when external palpa- 



988 



DISEASES OF THE DIGESTIVE APPARATUS. 



tion indicates merely the presence of fluid. If tumors are found, they 
may be fixed or floating, superficial or deep-seated. When fluid is aspi- 
rated, it is likely to have a high specific gravity, and to contain large 
and irregularly shaped cells, in which fat, hyalin, or glycogen may be 
found. At times a gelatinous fluid may be aspirated in which the 
structural characteristics of a malignant tumor are present. 

Diagnosis. — The diagnosis is based usually upon the recognition of 
the presence of abdominal tumors, often movable, associated with liquid, 
and preceded by disturbances of function in some one of the abdominal 
organs. It is confirmed by the aspiration of cancerous tissue, or by the 
withdrawal of fluid the specific gravity and glycogenic cells of which 
(according to Quincke) indicate its malignant origin. The differential 
diagnosis usually is between ascites and tubercular peritonitis. The 
presence of tumors after withdrawal of the fluid may exclude the former, 
while the absence of a family and personal history of tuberculosis, with 
evidence of this disease elsewhere in the body, would aid in the exclusion 
of tubercular peritonitis. 

Prognosis. — Since peritoneal cancer is usually secondary, not only 
does it have the general mortality of cancer, but its presence also in- 
dicates that the later stages of this disease are at hand, and that the 
patient has but a few remaining months to live. An immediately fatal 
issue may follow intra-peritoneal hemorrhage or perforation of the in- 
testine. Primary cancer of the peritoneum is usually of slow growth, 
although eventually fatal. 

Treatment.— The medical treatment of cancerous tumors of the 
peritoneum has no other effect than to afford temporary relief of the 
symptoms. 



SECTION YL 

DISEASES OE THE URINARY APPARATUS. 



CHAPTEE I. 

DISEASES OF THE KIDNEYS. 
ANOMALIES OF SHAPE AND POSITION. 

Anomalies in the size, shape, number, and position of the kidneys 
exist as a result of developmental or pathological disturbances, and are 
usually not productive of symptoms unless associated with pathological 
conditions elsewhere. The most important of these anomalies are the 
fused kidney and the floating kidney. 

The fused Mdney, which often, though not necessarily, suggests the 
shape of a horseshoe, is usually displaced downward, lying near the 
sacral promontory, and may be found in the pelvis. A single kidney, 
usually the left, also may be displaced downward. Such dislocated kid- 
neys may be mistaken for abdominal or pelvic tumors, have obstructed 
labor, and a dislocated fused kidney has been the immediate cause of 
death by pressing upon the inferior vena cava and producing throm- 
bosis and embolism. 

FLOATING KIDNEY. MOVABLE KIDNEY. WANDERING KIDNEY. 

NEPHROPTOSIS. 

Although a slight degree of mobility of the kidney normally exists in 
connection with respiration, the resulting change of position is usually 
insufficient to permit the lower edge of the kidney to be felt. Not infre- 
quently an otherwise normal kidney is freely movable even within wide 
limits and readily palpated. 

Etiology. — The movable kidney is stated to be found from five to 
ten times more often in females than in males, and is especially frequent 
in adults from thirty to fifty years of age, although it may be found in old 
age and in childhood. Congenital predisposing causes, as a superabun- 
dance of peritoneum, lax perinephric tissue, and elongated renal blood- 
vessels, are probably of importance. Among the acquired causes are the 
emaciation of a previously fat person and sudden changes in the resist- 
ance of the abdominal wall, snch as may occur after parturition or the 
removal of abdominal tumors. Pressure of tumors or of the pregnant 
uterus on the kidney, or increased weight of the organ, as from tumors 

989 



990 



DISEASES OF THE URINARY APPARATUS. 



or hydronephrosis, favor its displacement and mobility. It is maintained 
that repeated congestions of the kidney may occur during menstrua- 
tion and thus promote the occurrence of the floating kidney. The use 
of corsets is often considered to be an imi>ortant cause, and in consider- 
able part explanatory of the greater frequency of this anomaly among 
women. It is probable, however, that dislocation of the kidney must 
exist before the organ can be made movable by the pressure of corsets. 
Traumatism and prolonged excessive muscular contractions are also 
usually included among the causes. Of late years, since the publication 
of Glenard's work on enteroptosis, it has been generally recognized that 
movable kidney is frequently associated with displacement of the stomach 
or the intestine, of the liver, and of the uterus, often in combination 
with nervous, digestive, and nutritive disturbances, especially in young 
persons of a chlorotic type, thus rendering still more conspicuous the 
agency of congenital conditions in the production of the floating kidney. 

Morbid Anatomy. — The post-mortem recognition of the floating 
kidney is extremely rare, due in all probability to the failure to seek for 
this condition. Eotch has found in an analysis of eight hundred and 
sixty-seven cases that in upward of eighty per cent, the right kidney 
was affected, while the left kidney or both kidneys were movable in about 
ten per cent, of the cases. Elongation of the blood-vessels of the kidney, 
a curved ureter, hydronephrosis or pyonephrosis, limited twists of the 
ureter and blood-vessels, and adhesions to the transverse colon or liver 
have been found associated. The possible displacement of other abdom- 
inal organs has already been mentioned. 

Symptoms. — Floating kidney often produces no symptoms. Fre- 
quently it is accompanied with disturbances not attributable to the mo- 
bility of the kidney, and when symptoms are referred to the kidney they 
are usually associated with abnormalities of function elsewhere. The 
patient may be aware of the existence of a floating kidney during years 
of health, but may not assign importance to it until he has become 
weakened from other causes. 

The floating kidney may produce discomfort by causing a sensation 
of pressure or dragging and a feeling as of some moving object in the 
abdomen. Such symptoms may become apparent on change of position, 
especially when lying on one side or in stooping, when the floating 
kidney may become painful and tender. The pains may be fixed or 
shooting, and may be referred to other parts of the abdomen, as the 
back or the groins, or to other parts of the body, as the chest or the ex- 
tremities. The patients are often neurasthenic, and in women hysterical 
symptoms, especially at the menstrual period, are likely to occur, while 
men are frequently hypochondriacal. 

Disturbances of digestion, such as loss of appetite, nausea, vomiting, 
epigastric pressure or weight, flatulence, and constipation, are frequent. 
Jaundice sometimes occurs, rather as the result of a duodenal catarrh than 



DISEASES OF THE KIDNEYS. 



991 



as attributable to the pressure of the floating kidney on the common bile- 
duct. The digestive disturbances are those usually regarded as evidences 
of a nervous dyspepsia, although gastric catarrh, dilatation of the stomach, 
and, especially, prolapse of this organ, may exist. The dilatation of the 
stomach associated with floating kidney is often attributed to the direct 
pressure of the latter upon the pylorus or the duodenum. Landau at- 
taches importance to the floating kidney in the production of intermit- 
tent or permanent hydronephrosis and pyonephrosis, and asserts that in 
such cases traumatism may prove an immediate excitant of these com- 
plications by producing a twist of the ureter. Dietl first called attention 
to attacks of sudden, intense abdominal pain, followed by tenderness, 
swelling of the abdomen, and symptoms of collapse, perhaps with vomit- 
ing, chills, and fever, during which he found the region of the movable 
kidney painful and extremely sensitive, while palpation and percussion 
indicated the presence of a tumor in this region. The urine became 
scanty and often contained blood. In the course of a week the distress- 
ing symptoms diminished in severity and the flow of urine became abun- 
dant. Dietl considered that these symptoms were due to a circumscribed 
peritonitis from an incarceration of the kidney in the peritoneum sur- 
rounding it, while Gilewsky regarded the condition as an acute hydro- 
nephrosis from compression or twisting of the ureter, and Landau at- 
tributed it to a disturbance of circulation in the floating kidney caused 
by obstruction of the renal vessels, especially the vein, in consequence 
of a displacement or twist of the floating kidney. 

Although the position of the floating kidney is such that it is usually 
covered by more or less resonant intestine, it may exceptionally lie directly 
beneath the abdominal wall uncovered by intestine, and give rise to 
dulness on percussion. The floating kidney is usually recognized with- 
out difficulty by palpation, and the patient not infrequently has learned 
the most efficient means of causing it to come within reach. It may be 
that the sitting or lateral position is best adapted for this purpose, or the 
patient may better succeed by bending the body forward. The physi- 
cian usually most conveniently recognizes the floating kidney when the 
patient lies on the back near the edge of the bed, the muscles being 
relaxed as thoroughly as possible, the knees perhaps being raised for this 
purpose. The finger-tips of the one hand (the left if the right kidney is 
being examined, and the reverse in the case of the examination of the left 
kidney) should be pressed firmly against the right lumbar region while 
counter-pressure is applied from the front, the finger-tips being moved 
about. If the circumscribed, smooth, rounded, and dense kidney is not to 
be felt, the patient should be asked to draw a long breath, when the lower 
portion of the descending kidney is often appreciated. The floating kid- 
ney when found out of place may lie as low as the brim of the pelvis, or 
on the opposite side of the median line, or directly beneath the anterior 
abdominal wall, and, as a rule, is readily returned to its normal position. 



992 



DISEASES OF THE URINARY APPARATUS. 



Most observers find that the urinary secretion is in no way modified. 
Landau, however, states that he often has observed alterations in the 
quality and quantity of the urine, which may be increased or diminished 

even to complete suppression, as in the class of cases referred to by 
Dietl, and may contain blood, especially when the region of the kidney is 
painful. The presence of pus is to be expected when pyonephrosis is a 
complication. 

Diagnosis. — The diagnosis of the floating kidney is made by palpa- 
tion, which determines the seat, shape, size, and consistency of the ab- 
dominal tumor, which can usually be pushed into the site of the kidney. 
In cases of doubt the patient should be palpated in the knee and elbow 
position, in order to allow the kidney to fall forward. Since the symp- 
toms attributed to a floating kidney may occur in its absence, and the 
floating kidney be often found without symptoms, the rational signs afford 
but little aid in diagnosis. The patient is often the first to find the tumor, 
which is regarded as a curiosity by some and the cause of serious dis- 
turbance by others. It may be judicious for a physician, if he is the 
first to discover the abnormality, to refrain from giving the information 
to his patient, since the latter might exaggerate its pathological sig- 
nificance. 

Eetained faeces, a dropsical gall-bladder, a tongue-shaped appendage 
to the right lobe of the liver from constriction or growth, and pedunculate 
tumors of the uterus or ovary, are the conditions most often to be differ- 
entiated. The free use of laxatives will cause the disappearance of the 
fsecal tumor. Tumors connected with the liver are more constantly super- 
ficial, and the degree of their mobility is more largely controlled by that 
of the diaphragm, while the inability to replace them in the region of 
the kidney will usually suffice to avoid confounding such tumors, as well 
as the pedunculate uterine or ovarian tumor, with the kidney. Cancer 
of the stomach or the intestine when physically simulating the movable 
kidney, if not at first to be differentiated by the symptoms, soon becomes 
characterized by severe digestive disturbances. The difficulties of differ- 
ential diagnosis are such that an exploratory laparotomy has frequently 
been undertaken and the renal nature of the abdominal tumor first recog- 
nized by this means. 

Prognosis. — The floating kidney may eventually become fixed and 
incapable of recognition and the discomfort disappear. This result may 
be owing to the accumulation of fat-tissue, to pregnancy, or to mechanical 
or surgical treatment. The prognosis as regards relief from the perma- 
nent mobility of the kidney is, therefore, favorable. The symptoms at- 
tributed to the floating of the kidney may persist when the latter is no 
longer movable, and may disappear although the kidney is still palpable. 
The prognosis of the symptoms attributed to the floating kidney is rather 
that of the associated chlorosis, neurasthenia, or hypochondriasis, and the 
distress may often be relieved by an intelligent appreciation on the part 



DISEASES OF THE KIDNEYS. 



993 



of the patient of the significance of the floating kidney, as well as by the 
fixation of this organ. It may also be noted that the symptoms attributed 
to a floating kidney not infrequently disappear after the climacteric. If 
hydronephrosis or pyonephrosis is caused by the floating kidney, the 
prognosis may then be more favorable than if these conditions were due 
to other causes. The surgical treatment of floating kidney of late years 
has made its prognosis as to life more serious. 

Treatment. — Eestoration of floating kidney can usually be obtained 
without difficulty by placing the patient upon the back and gently push- 
ing the kidney in place. If medical advice has been sought immediately 
after the forcing out of the kidney by some strain, it is worth while to 
attempt by enforced rest in the recumbent position to bring about perma- 
nent natural fixation of the organ. Yery rarely, however, in practice 
do the circumstances favor such an attempt. The effort should always be 
made to keep the kidney in its place by mechanical means. We have 
seen complete cures thus obtained, although the result is often unsatis- 
factory. The best bandage is made of silk elastic closely fitted to the 
whole abdomen of the patient, and prevented from riding up by means 
of straps of soft rubber tubing or similar material, one on each side, pass- 
ing from back to front between the legs. Over the position of the dis- 
located kidney is sewed on the inside of the bandage a round pocket of 
soft chamois-skin, left open above so that a pad can be pushed into it and 
changed on occasion. Success depends largely upon the skill of the 
maker in fitting and adjusting and the patience of the subject in enduring 
annoyance until habit has produced toleration. 

The medicinal palliative treatment in floating kidney is often very 
effective in the relief of symptoms, but so closely depends upon the 
adaptation of the means to the individual case that we can do little more 
than point out the general principle that a dislocated organ is extremely 
irritable, and that the reflex and other symptomatic phenomena are chiefly 
due to this irritation. If a gouty diathesis exists, its effects will be greatly 
exaggerated, so that careful treatment for this condition often brings 
about the most happy results. Bromides and other sedatives allay ner- 
vous irritability for the time being, but are temporary in their action, 
and are to be avoided as much as possible. 

The question of surgical operation is to be decided largely from the 
circumstances of the case. The daily occupation, the amount of influence 
upon the general health, the physical discomfort, and the courage of the 
patient, all are elements in making up an opinion. Two operations are 
performed, — nephrorrhaphy, or stitching the kidney to the posterior ab- 
dominal wall, and nephrectomy, or removal of the kidney. The former 
of these is a comparatively safe operation ; according to Delvoie, in two 
hundred and fifteen cases there were five deaths and one hundred and 
thirty-five recoveries. Nephrectomy is much more serious ; Sulzer gives 
the mortality at twenty-seven per cent, Newman at thirty per cent. 

63 



994 



DISEASES OF THE URINARY APPARATUS. 



Nephrectomy for movable kidney is never justified unless the symptoms 
are very severe and disabling and nephrorrhaphy has been tried twice 
and failed. 

ABNORMALITIES OF THE URINE. 

The importance of an examination of the urine both in diagnosis and 
in prognosis is such that it is desirable to call attention to some of its most 
important abnormalities before considering the diseases of the kidney, 
the recognition of which is so frequently dependent upon the condition of 
the urine. The variations in the quantity and quality of the urine passed 
during the day and at night may make it important not only to ascertain 
the total amount passed within twenty-four hours, but also to make sepa- 
rate measurements and separate chemical and microscopical examinations 
of the urine voided during the day and of that secreted in the night. 
Errors due to the examination of a single specimen may be avoided if a 
sample, six or eight ounces, of the mixed and preserved total amount 
passed in the twenty-four hours is investigated. 

Although the normal quantity passed in twenty-four hours is about 
three pints, variations in this amount, unless excessive (diminished to 
one pint or increased to three quarts), are within physiological limits. 
A diminution in quantity is of especial significance in varieties of ne- 
phritis, and if persistent in any disease is an important danger signal. 
An increased quantity of urine, three quarts and upward, polyuria, may 
be an important sign of renal disease, or a characteristic symptom of 
diabetes, although an excessive flow of urine may be indicative of no im- 
mediate danger, but rather of a favorable condition when it gives evi- 
dence of the absorption of pathological accumulations of fluid in various 
parts of the body. 

The normal color of the urine varies largely in accordance with the 
quantity passed. Abnormal coloration is the result of the presence of 
pigments derived from the body or from without. Of the former, biliary 
pigment is the most frequent, and is considered in the section on jaun- 
dice. The urine may be abnormally colored from blood-pigment, or 
from a transformation of some of the constituents of the tissues, whether 
normal or pathological, or from the presence or action of agents intro- 
duced from without. Rhubarb and senna may produce shades of brown 
(reddish brown if the urine is alkaline), and santonin a yellow or greenish 
tint simulating the discoloration produced by biliary coloring matter. 
Carbolic acid, salol, and pyrogallic acid in sufficient quantity produce a 
dark-green or black color, the urine becoming darker in color the longer 
it is exposed to the air. When the urine contains chyle the appearance 
resembles that of milk. 

Blood coloring matter may be present in the urine, either contained 
within the red blood- corpuscles, hematuria, or separated from them in 
solution or precipitated, hemoglobinuria. 

Haematuria. — Eed blood-corpuscles, pigmented or decolorized, may 



DISEASES OF THE KIDNEYS. 



995 



be found in the urine with the microscope when not present in sufficient 
quantity to cause macroscopic alterations in color. Blood not proceed- 
ing from the urinary tract may be present in the urine, especially in 
that of the female, the source of the bleeding being uterine, vaginal, or 
anal. The physical examination of these possible sources, or catheter- 
ization of the bladder to eliminate extra- vesical hemorrhage, will suffice 
to make clear the region in which the bleeding takes place. 

The color of the urine in hematuria varies in accordance with the 
quantity of blood present, the length of time it has been in the urine, 
and the secondary changes it may have undergone after the urine has 
been voided. The color, therefore, may be more red or brown. The 
presence of red blood-corpuscles is determined by the microscope, and 
blood-pigment is precipitated with the earthy phosphates by heating the 
urine in a test-tube after one-third its volume of liquor potassse has been 
added. To determine the source of hemorrhage the urine is allowed to 
stand undisturbed for several hours. If the hemorrhage arises from 
below the kidney, and especially from the bladder, a sediment of red 
blood- corpuscles rapidly forms, and the overlying fluid, particularly in 
urine which has not been long retained, is relatively free from blood 
coloring matter, and contains but little albumin unless there is concurrent 
disease of the kidney. Blood- clots are likely to be present, perhaps 
worm-like and sometimes decolorized if from the renal pelvis or the 
ureter, while those from the bladder are larger, of irregular shape, and 
often shreddy. A vesical source of the hemorrhage is to be suspected 
if at the end of micturition the urine appears more bloody than that 
first passed, and if after emptying the bladder the catheter is inserted 
and repeated washings are returned stained with blood. If the blood is 
of renal origin, the color is of a less bright red : the sediment contains 
no clots unless large vessels are ruptured, and the uppermost portions 
of the urine contain more or less albumin. Both blood- casts and other 
varieties of casts may be found in the sediment, and, according to Gum- 
precht, fragments of red blood-corpuscles are present, which is not the 
case when the hemorrhage arises at a point below the kidney. 

Etiology. — The causes of hseinaturia are local and general. Eenal 
hematuria is the result of injury to the kidney, renal thrombosis and 
embolism, nephritis, both acute and chronic, malignant tumors, calculi, 
and parasites of the kidney. Calculi, local tuberculosis, acute cystitis, 
and villous tumors of the bladder are the most frequent local causes of 
hematuria from below the kidney. General causes of hseinaturia are 
scurvy, purpura, haemophilia, and malaria. 

Diagnosis. — The recognition of a traumatic cause for renal hsematuria 
is sufficiently obvious. The diagnosis of a thrombus of the renal vein 
is based upon an appreciation of the local and general causes of throm- 
bosis. The diagnosis of embolic renal hemorrhage, which is but tran- 
sitory, demands evidence of a probable source of embolism in the left 



996 



DISEASES OF THE URINARY APPARATUS. 



ventricle of the heart or in the aorta. If the hemorrhage is due to ne- 
phritis, the small quantity of blood, the excessive amount of albumin, 
the nature of the sediment, and the accompanying dropsy suffice to 
explain the cause of the hematuria. Cancer of the kidney is always 
to be suspected as a source of prolonged renal hemorrhage of obscure 
origin, although the physical evidence of a tumor not infrequently may 
occur some time after the appearance of the hemorrhage ; if the hema- 
turia be accompanied by a general unaccountable failure of health and 
a heavy persistent pain, either in the kidney itself or, as often happens, 
above and anterior to the usual seat of renal pain, the diagnosis of 
cancer will be justified. The parasitic source of the hemorrhage is 
manifested by the discovery of filarie in the urine or in the blood when 
sought for at night. Eenal colic or vesical pain, obstruction to the flow 
of urine, discomfort on motion, and the frequent presence of pus are 
suggestive of calculi and cystitis as the cause of the hemorrhage, while 
the characteristic bacilli and villosities may make clear the diagnosis of 
tuberculosis or villous tumor. The symptoms characteristic of the gen- 
eral causes of hematuria are described at length in the consideration 
of the diseases mentioned. Malaria as the cause of hematuria is made 
evident by its association with the symptoms and signs of this disease, 
its frequent occurrence during a period of years, and the absence of other 
symptoms indicative of disease of the urinary tract. 

Treatment. — The radical treatment of hematuria is that of the con- 
dition which produces it. For the relief of the hemorrhage, gallic acid — 
ten to fifteen grains every two to four hours — is usually the most effective 
remedy, and has the advantages of not being irritant to the kidney and 
of not influencing seriously the general system. Extract of ergot is some- 
times useful. When there is no irritation of the kidney, various volatile 
oils may be serviceable ; at the head of these we would place oil of erigeron, 
ten to twenty drops every two to four hours. Oil of turpentine is more 
irritating and usually less efficient. In continuing cases, ferric chloride, 
one to two grains, or tincture of ferric chloride, ten to twenty minims, 
may be used. Monsel's solution, two to five minims every two to four 
hours, sometimes does well. All these remedies must be given freely 
diluted. 

Hemoglobinuria. — This term is applied to the presence of the color- 
ing matter of the blood in the urine, few or no red blood- corpuscles being 
present. According to Hoppe-Seyler, the coloration is due to niethenio- 
globin, whose presence is indicated by means of the spectroscope. That 
the abnormal color of the urine is due to blood-pigment is made evi- 
dent by its precipitation with liquor potasse, and, if necessary, by the 
production of hemin crystals in the dried pigmented sediment when it is 
heated after the addition of a little glacial acetic acid and a few crystals 
of common salt. The diagnosis of hemoglobinuria is thus based upon 
the presence of blood-pigment and the absence of red blood- corpuscles. 



DISEASES OF THE KIDNEYS. 



997 



Etiology. — Haemoglobin occurs in the urine when the blood coloring 
matter is freed from the red blood-corpuscles in the blood-vessels, hseino- 
globinaemia, although it may take place when there is no appreciable free 
haemoglobin in the blood, and may occur in the course of severe infectious 
diseases, especially in scarlet fever, erysipelas, typhoid fever, and malaria, 
in which micro-organisms or their products are probably the efficient 
cause in setting free the haemoglobin. W. S. Bigelow has called attention 
to this condition in infectious diseases of new-born children, and Winckel 
has described its epidemic occurrence among them. A certain importance 
in etiology is to be attached to heredity. Hemoglobinuria may be the 
result of extensive burns and of poisoning with various agents, the more 
important of which are mushrooms, carbolic acid, naphtol, pyrogallic 
acid, corrosive sublimate, and potassium chlorate, or of the introduction 
into the veins of foreign blood or serum ; in an animal the intravenous 
injection of pure water may dissolve the red blood- corpuscles and pro- 
duce hgemoglobinuria. Its periodical occurrence is usually regarded as a 
disease, paroxysmal hemoglobinuria. The occurrence of hemoglobinuria 
in connection with the above-mentioned causes adds greatly to the gravity 
of the prognosis. 

The urine often is red when passed, becoming darker on standing, 
with subsequent fading of the color, and the odor may resemble that of 
fresh meat, from the presence of haematoporphyrin. This pigment is a 
derivative of haemoglobin, essentially haematin without iron, and is to be 
recognized by means of the spectroscope. According to Garrod, it is 
almost always present in the urine, and a moderate variation in its 
quantity is of no especial significance. It has been found notably in- 
creased in poisoning by sulphonal and by trional, and has been observed 
in excess in the urine of the insane and the neurasthenic and of typhoid 
patients. Such excess is to be regarded as a bad prognostic sign. 

Treatment. — The radical treatment of haemoglobinuria is that of its 
cause. As the destruction of the red blood- corpuscles does not take place 
in the kidneys, it is better that they should remove liberated haemoglobin 
from the blood : so that styptics are of little value. 

Paroxysmal Haemoglobinuria. — Syphilis and malaria are stated to 
offer a predisposition to this condition. It occurs most frequently in 
male adults, and the paroxysms may be excited by exposure to cold, 
even by dipping the hands or the feet in cold water, and, according 
to Chvostek, by ligature of the finger. Mental excitement or physical 
exertion may also bring on an attack. 

Symptoms. —The paroxysms consist frequently of a chill followed by 
fever, the temperature rising to 104° F. Pains are present in the back 
and hips and sometimes in the extremities, respiration is labored, and 
the chest feels constricted. The skin in general is pale, although the 
finger-tips and ears are cyanotic, and there is slight jaundice at times, 
also urticaria or circumscribed oedema. Defervescence, with sweating 



99S 



DISEASES OF THE URINARY APPARATUS. 



and relief to the symptoms, takes place during the course of a few 
hours. During the attack the urine has the characteristic dark red or 
brown appearance, and amorphous haemoglobin is found with the micro- 
scope. Casts, renal epithelium, and crystals of calcic oxalate may be 
present. Albumin may be detected in the urine at the beginning of 
the attack before the appearance of the haemoglobin, and it may persist 
for several days after the haemoglobin has disappeared. Auscultation 
of the heart often discloses a faint systolic murmur, and the liver and 
spleen at times are found enlarged. Between the attacks the patient 
merely appears pale and weak. 

Prognosis. — Paroxysmal hemoglobinuria is a chronic affection, last- 
ing for years. It is not known as an immediate cause of death, and 
recovery may take place. 

Treatment. — The treatment of paroxysmal hemoglobinuria depend- 
ent upon malaria has already been described. The treatment of a non- 
malarious attack should be purely symptomatic ; between the attacks 
attention should be directed to the building up of the general strength 
of the patient, and especially to the removal of any diathetic or other 
irritation of the kidneys. If diuretics be used, they should always be 
of the non-irritating class, such as potassium bitartrate. 

Urobilinuria. — Urobilin and indican, normally present in the urine, 
may be in such excess as to give rise to a dark red or brown color. 
Liebermann has shown that urine containing an excess of urobilin when 
shaken produces a yellow foam. Its presence may be determined by 
adding sufficient ammonia to the urine in a test-tube to make it strongly 
alkaline, then adding eight to ten drops of a ten per cent, solution of 
chlorate of zinc and immediately filtering the specimen. Transmitted 
light causes the nitrate to appear of a red color, but with a dark back- 
ground and by reflected light the color is fluorescent green. The pres- 
ence of urobilin may be inferred in high-colored urine if bilirubin and 
indican are shown to be absent. It is found in excess in fevers and in 
internal hemorrhage ; it may also exist in diseases of the liver, especially 
in fibrous hepatitis, and serve as the cause of a mild jaundice. Its 
recognition may be of especial clinical importance in cases of concealed 
hemorrhage, especially in ectopic gestation, in which excessive urobili- 
nuria may indicate that the absorption of extravasated blood is taking 
place. 

Indicanuria. — An excess of indican, sulphate of indoxyl, also pro- 
duces a dark brown color of the urine, and is to be suspected if the urine 
does not foam when shaken and contains no biliary coloring matter. Its 
existence may be determined by Jaffe's test, which consists in adding 
equal parts of urine and strong hydrochloric acid in a test-tube. A solu- 
tion of chlorinated soda, 1 to 20, is then added drop by drop, the mixture 
being shaken. If indican is present a green color is formed, or if it is 
in excess the urine becomes blue from the formation of indigo, and the 



DISEASES OF THE KIDNEYS. 



999 



green or bluish color will disappear on the addition of an excess of 
chlorinated lime. If there is no increase of indican the urine becomes 
red. 

This coloring matter is formed from indol, which is produced as the 
result of the action of intestinal bacteria on albumin. Indol is absorbed, 
transformed into indoxyl, and, in combination with sulphuric acid, elim- 
inated in the urine as indican. 

An excess of indican in the urine indicates increased putrefaction of 
albumin in the intestine : hence it is present when there is prolonged stag- 
nation of the intestinal contents in the ileum. In stagnation of the con- 
tents of the large intestine there is no considerable increase of indican, 
since in this portion of the bowel the albuminous material is usually 
insufficient to produce an excess of indol. In the new-born child there 
is no indican in the urine, since the bowel contains no putrefactive 
bacteria. In starvation the indican may result from the decomposition 
of the albumin of the intestinal secretions. Yon Jaksch has found ex- 
cessive indicanuria in ichorous pleurisy. It may also be found in chronic 
wasting diseases, as ulcer and cancer of the stomach, in chronic tubercu- 
losis, especially with diarrhoea, and in acute diarrhoea and cholera. The 
rapid putrefaction of an excess of albuminates in the urine, as in chronic 
cystitis, may occur, and cause the precipitation of indigo in the urinary 
tract with the formation of an indigo calculus, as reported by Ord, or the 
passage of a blue urine, or the urine may become blue on exposure to the 
air. The recognition of excessive indicanuria is of especial importance 
in the diagnosis of intestinal obstruction, which is often simulated by a 
general or circumscribed peritonitis, in which there is no excess of indi- 
can. In diffuse suppurative peritonitis, although indican is increased, 
it is not as abundant as in intestinal obstruction. The greatest excess 
of indican is to be found in the latter affection when the small intestine 
is obstructed. 

Melanuria. — The urine at times is of a dark color from the presence 
of a black pigment, melanin, which may be in solution or in a granu- 
lar form. Such discoloration is present when the urine is first passed, or 
becomes apparent after the urine has been exposed to the air for some 
time. The latter condition is explained by the presence of melanogen, 
which when oxidized becomes transformed into melanin. In either case 
the discoloration may be intensified by the addition of oxidizing agents, 
as sulphuric or hydrochloric acid. 

Melanuria has been found in patients with melanotic tumors, although 
such tumors may be present and melanuria be absent. It has also been 
found in emaciated persons. Its occurrence is suggestive of a melanotic 
cancer or sarcoma, especially in those cases in which other symptoms or 
signs favor such a diagnosis. 

Alkaptonuria. Brenzkatechinuria. Hydrochinonuria. — Urine 
which when passed is of a normal color may become dark-colored, some- 



1000 



DISEASES OF THE URINARY APPARATUS. 



times black, on standing, even when melanin or melanogen is absent, 
and may be alike discolored by the addition of canstic potash or soda. 
Boedeker gave the term alkapton to the snbstance producing this dis- 
coloration. Baumann ascribed a similar modification of color to brenz- 
katechin ; while importance has been attached to still other chemical 
compounds which have been isolated from such pigmented urine. It is 
therefore probable that the so-called alkaptonuria may be due to a variety 
of substances. 

Alkaptonuria has been more frequently found in children than in 
adults. It has been observed in two children of the same parents, and 
has continued throughout life in a person attaining sixty years of age. 
So far as is known, it produces no ill effects and has no diagnostic impor- 
tance, except that it may cause the urine to react like that of diabetes 
when Heller's, Trommer's, and Fehling's tests are employed, although 
it does not respond to the fermentation test. The urine may be brownish 
when passed, becoming darker, or even black, on standing, from the 
presence of hydrochinone, due to poisoning by carbolic acid, salol, resor- 
cin, and uva ursi. The appreciation of this fact is of importance, 
especially during the therapeutic administration of carbolic acid, as evi- 
dence of a beginning toxaemia. 

Chyluria. Lipuria. — Fat may be present in the urine either in the 
molecular form or as fat- drops or solidified fat. 

In chyluria, or galacturia, the urine has the opaque white homoge- 
neous appearance of milk, and if blood also is present a pink color is 
produced. A cream-like layer may form on exposure to the air, and a 
fibrinous clot be present. The urine contains albumin, sometimes in con- 
siderable quantity, and on microscopical examination molecular fat, small 
fat-drops, leukocytes, and at times red blood-corpuscles, are to be found. 
If the milky urine is made alkaline and shaken with ether, the fat is 
dissolved and the urine appears clear. 

Chyluria is considered to be due to the flow of lymph into the uri- 
nary tract, although the urine is free from sugar, which is always pres- 
ent in lymph, and the quantity of fat in a chylous urine is greater than 
that present in lymph. The occurrence of chyluria in regions near the 
tropics is occasioned by the presence in the lymph- vessels of a para- 
site (the filaria sanguinis hominis), which probably enters the body 
with drinking-water, and which is further considered in the chapter on 
animal parasites (page 368). It is likely that a non-parasitic variety of 
chyluria also exists, from the fact that this symptom occurs in persons 
who have never been near the tropics, and may last for years without 
other disturbance than painful micturition from the presence of clots in 
the bladder. 

In lipuria, or adiposuria, the fat is present either as large or small oil- 
drops or as solidified fat resembling lard or tallow. The fat is usually 
liquefied while the urine is warm, but may become solidified as the urine 



DISEASES OF THE KIDNEYS. 



1001 



cools. It may be sufficient to grease blotting-paper, or may be recog- 
nizable only by means of the microscope, the appearances being con- 
trolled in case of need by the solution of the fat-drops in ether or chloro- 
form or by their black discoloration with osmic acid. The solidified fat 
when heated becomes liquefied. 

The fat may directly enter the urinary tract or be eliminated from the 
blood : in the latter case a lipsemia (free fat in the blood) exists, which 
is produced in various ways. In animals where an excess of fat is intro- 
duced into the blood, it is eliminated as oil by the kidney, and it is pos- 
sible, though not probable, that excessive quantities of oil taken into 
the human stomach may be in part excreted by the kidneys as oil. 
Minute quantities of fat may pass through the kidneys when the exten- 
sive crushing of fat-tissues, especially of bone-marrow, as in fracture, 
has taken place. Lipuria has been observed in saccharine diabetes and 
in cancer of the pancreas. Fat is also present in the urine as the result 
of its direct admission, either in consequence of a fatty degeneration 
of the renal epithelium, of pus in pyonephrosis, of tumors projecting 
into the renal pelvis, or from inflammatory destruction of the perine- 
phric fat-tissue. In phosphorus poisoning, in chronic alcoholism, and in 
phthisis the presence of fat in the urine is attributable to the elimi- 
nation of fat from the blood as well as to its formation in the kidney. 
Excessive quantities of fat in the urine offer suggestive evidence of 
pyonephrosis, perinephritis, diabetes, or cancer of the pancreas. 

ALBUMINURIA, GLOBULINURIA, NUCLEO ALBUMINURIA 
(MUCINURIA), ALBUMOSURIA, PEPTONURIA. 

A variety of albuminous substances may occur in the urine. Those 
which receive especial consideration are serum-albumin, serum-globulin 
(paraglobulin), nucleoalbumin (mucin), albumose, and peptone. Most 
constant and most abundant is serum- albumin, with which serum-globulin 
is usually, but not, according to Von Jaksch, always, combined. The 
cases are rare in which the former is absent and the latter alone present, 
although Senator and Werner have observed instances of acute nephritis 
in which globulin was the sole albuminous constituent of the urine. 
Strictly speaking, the term albuminuria applies to the presence in the 
urine of serum-albumin alone. 

Albuminuria. — In most instances the albuminous material of the 
blood transudes through the walls of the blood-vessels of the kidney either 
into Bowman's capsules or into the tubules. This renal albuminuria is to 
be distinguished from an admixture of albumin with the urine, which may 
take place anywhere in the urinary tract from the presence of blood, pus, 
semen, lymph, or fragments of tumors. In renal albuminuria the quan- 
tity of albumin is the same in all parts of the fluid. In albuminuria 
from other sources the percentage of albumin is in proportion to the 
quantity of blood, pus, lymph, or other albuminous fluid present, and is 



1002 



DISEASES OE THE URINARY APPARATUS. 



often higher at the bottom of the vessel in which the urine has been 
allowed to stand for some time than in the npper portion of the urine. 
The absence of casts and renal epithelium, and the presence of blood and 
pus- corpuscles, of spermatozoa and degenerated cells of uncertain origin, 
are opposed to the renal origin of the albuminuria. It is, however, to be 
remembered that renal albuminuria also may be present in cases in which 
albumin enters the urine from sources beyond the kidney. The diagnosis 
of renal albuminuria may require the exclusion of such sources of albumin 
as well as a characteristic sediment, or the presence of the symptoms and 
signs of disease of the kidney. 

In testing for albumin it is desirable, especially when small quantities 
are concerned, that the urine should be dilute, to avoid an excessive pre- 
cipitation of urates, and transparent. If simple nitration does not suffice 
to render the urine clear, a preliminary shaking with calcined magnesia 
is advantageous $ but if the specimen is opaque from the presence of fat, 
the latter may be removed by shaking with potash and ether. The tests 
in common use and sufficient to permit the recognition of one-fiftieth of 
one per cent, of albumin are nitric acid and heat, and potassium ferro- 
cyanide. 

Nitric Acid and Seat — A glass capable of holding an ounce is to be 
filled one-fourth with urine. Nitric acid is to be slowly poured down 
the side of the tilted glass until it forms at the bottom a layer one-third 
of an inch thick. The presence of albumin is indicated by an opaque 
white line at the junction of the two fluids, and may be made more con- 
spicuous by placing the glass against a dark background. A like result 
is obtained if the mine, by means of a pipette, is made to form a layer 
upon the upper surface of the acid. The denser and wider the albumi- 
nous ring, the larger the quantity of albumin. Globulin, albumose, urates, 
and resins, when present, are also precipitated. The urates form a zone 
farther removed from the acid, disappearing on the addition of heat, as 
does albumose ; resins are dissolved in ether. For the sake of control 
another specimen of urine is to be boiled in a test-tube. If a precipitate 
occurs, it may be due to albumin or phosphates. The addition of acetic 
or nitric acid causes the latter to be dissolved, while the former persists 
or becomes increased, although a minute trace of albumin may be dis- 
solved in acetic or nitric acid. If a precipitate does not form until the 
specimen becomes cold, it is suggestive of albumose. 

Potassium Ferrocyanide. — This test is extremely sensitive, and requires 
that the urine, when of high specific gravity, should be diluted. A 
test-tube is to be one-fourth filled with the transparent diluted urine, 
which is then to be acidified with acetic acid. If an opacity occurs, it 
may be due to nucleoalbumin (mucin), globulin, urates, or resins, and 
the specimen is then to be filtered and a few drops of a ten per cent, solu- 
tion of potassium ferrocyanide are to be added. The slightest trace of 
albumin is shown either at once or in a few minutes by an opacity, 



DISEASES OF THE KIDNEYS. 



1003 



while a larger quantity is indicated by a flocculent precipitate. Globulin 
and albumose, if present, are dissolved by heating the fluid. 

An approximate test of the quantity of albumin present, sufficient for 
practical purposes, is furnished by boiling a specimen of urine and add- 
ing one-tenth of its volume of dilute nitric acid and allowing the sedi- 
ment to settle. If, according to Klemperer, after several hours the fluid 
is simply opaque, a trace of albumin, one-hundredth per cent., is indicated. 
If the concave portion of the test-tube is filled with the sediment, five- 
hundredths per cent, are represented. If the sediment occupies one-tenth 
of the volume of urine, it approximates one-tenth per cent. ; if one-fourth 
of the volume of urine, twenty -five-hundredths per cent ; if one-third of 
the volume of urine, five-tenths per cent. ; and if one-half of the volume 
of urine, one per cent. If the coagulated albumin reaches the surface 
of the urine, it represents from two to three per cent, of albumin. In 
the nitric acid test the thickness of the layer of albumin in fractions of 
an inch is estimated by Hofmann and Ultzmann to correspond to the like 
fractions of one per cent. For example, a thickness of one-fourth of an 
inch indicates twenty -five-hundredths per cent, of albumin. 

Esbach's albuminimeter offers a convenient means of approximately 
determining the quantity of albumin. In a graduated tube definite pro- 
portions of urine and the precipitating reagent are mixed and allowed to 
stand for twenty-four hours. According to the height of the sediment is 
the percentage of albumin determined. The chief value, however, of the 
Esbach tube is in the comparison of albuminous precipitates in successive 
examinations of the urine of the same patient. 

A trace of albumin has so often been found, especially by means of 
delicate tests, in the urine of apparently healthy individuals, perhaps for 
a short time only and in consequence of especial exciting causes, that 
it is generally admitted that albuminuria is not necessarily an evidence 
of disease. A distinction is hence drawn between a 'physiological and 
a pathological albuminuria, although the border-line is not to be sharply 
defined. Among the causes of the former are pregnancy, in which 
albumin has been found in the urine in more than one-half of a consider- 
able number of cases, the eating of large quantities of food, especially if 
abundantly albuminous, as eggs and cheese, extreme mental or muscular 
activity, and cold baths. Such an albuminuria, in virtue of its depend- 
ence upon physiological functions and its recurrence with the excessive 
use of these functions, and from the fact that it is of most frequent occur- 
rence among the young, even the new-born, has also been called func- 
tional, transitory, cyclic, intermittent, or the albuminuria of adolescence. Da 
Costa calls attention to the frequent association of uric acid and oxaluria 
with this variety of albuminuria, and is inclined to attribute the latter 
to disturbances in the kidney caused by the excretion of uric acid or 
oxalates. 

Pathological albuminuria may also occur as a transitory condition inde- 



1004 



DISEASES OF THE URINAEY APPARATUS. 



pendent of any serious disease of the urinary apparatus. It is more or 
less constantly present in acute infectious diseases, especially typhoid 
fever, acute rheumatism, pneumonia, erysipelas, and tonsillitis, and dis- 
appears in convalescence. Such an albuminuria is called febrile or infec- 
tious, and is regarded by some, especially when casts are present, as 
evidence of the first stage of a nephritis. In chronic diseases, especially 
those associated with modifications in the composition of the blood, as 
ansemia, leukaemia, pseudo-leukaemia, purpura, and scurvy, albuminuria 
may be present, and is to be regarded as pathological. It may also occur 
in neurasthenia, migraine, chorea, epilepsy, delirium tremens, and cerebral 
hemorrhage, and is then classified as a neurotic albuminuria. A transitory 
pathological albuminuria may be present in acute diarrhoea, in incar- 
cerated hernia, and in jaundice. The albuminuria associated with dis- 
ease of the urinary apparatus is always to be regarded as pathological, 
and may be either transitory or permanent. The former occurs in 
localized lesions of the kidney, as hemorrhagic infarction, abscesses, or 
tumors of this organ ; also in prolonged retention of urine, especially 
when caused by obstruction of the ureter from compression or a twist. 
It may be transitory or permanent according to the cause in active and 
passive congestions of the kidney and in the inflammations and degenera- 
tions of this organ, including the nephritis of pregnancy. 

The diagnosis of a physiological albuminuria should be made with 
caution, since evidence of a nephritis may eventually appear, and the 
causes productive of the physiological variety may aggravate a patho- 
logical albuminuria. An albuminuria may be regarded as physiological 
when it is slight, and when its existence and duration are dependent upon 
the presence and persistence of the causes above mentioned. Frequent 
and periodical examinations of the urine are therefore necessary in doubt- 
ful cases before freedom from renal disease can be positively asserted. 
On the contrary, the albuminuria, whether slight or severe, transitory or 
persistent, is to be regarded as pathological when not attributable to 
physiological conditions or when associated with evidence of disease of 
the urinary apparatus. Its persistence offers important, although not 
essential, evidence of its pathological nature. 

The prognosis of albuminuria, whether physiological or pathological, 
depends upon the cause and the possibility of the removal of the latter. 
If the albuminuria is persistent, its prognosis is more serious than if it 
is transitory or intermittent, since persistent albuminuria in the course 
of time not infrequently becomes associated with other evidence of 
disease of the kidney. The mere loss of albumin has no especial sig- 
nificance, since it may be excessive in acute nephritis and recovery take 
place, and is least in chronic fibrous nephritis, the prognosis of which 
is hopeless. 

Globulinuria. — Globulin may be tested for by diluting a considerable 
quantity of urine with distilled water to a specific gravity of 1001 or 1002. 



DISEASES OF THE KIDNEYS. 



1005 



If globulin is present, a white precipitate forms on the addition of a few 
drops of dilute acetic acid. 

Nucleoalbuminuria. — Of the other albuminous substances which 
may be found in the urine nucleoalbumin and albumose (hemialbumose 
or propeptone) may be mentioned. Nucleoalbumin is precipitated by 
acetic acid, and is insoluble in an excess of this reagent. Such a pre- 
cipitate was formerly called mucin, and was considered to be a normal 
constituent of the urine, and to be increased in inflammation of the 
mucous membrane of the urinary tract. Eecent investigations, however, 
show that two substances have been called mucin, the one true mucin (a 
giycoproteid which reduces copper) and the other nucleoalbumin. The 
former has never been found in the urine ; but nucleoalbumin is con- 
stantly present, and is found in excess in catarrhal affections of the uri- 
nary tract. Nucleoalbumin is tested for by adding three times as much 
water to the quantity of urine to be examined, filtering, if necessary, 
and adding an excess of acetic acid to the fluid, when nucleoalbumin 
is precipitated. 

Albumosuria. Peptonuria. — The recognition of albumose in the 
urine has become of importance of late years, since it requires to be 
differentiated from a group of albumoses whose presence in the urine has 
been designated peptonuria. Albumose or propeptone is considered to 
represent that stage of the products of the digestion of albuminous sub- 
stances immediately preceding the ultimate result, — peptone. Kiihne 
found that what had been called peptone represented a series of albu- 
moses, and limited the term peptone to substances not precipitated by 
ammonium sulphate. The term albumosuria or propeptonuria as now 
used designates the presence of albuminous substances soluble in heat, 
precipitated by cold and a concentrated solution of ammonium sulphate, 
and presenting the biuret reaction. A pure albumosuria may be sus- 
pected if nitric acid causes a precipitate in the urine which is dissolved 
by heat. Usually, however, albumosuria and albuminuria are combined, 
and the precipitate caused by nitric acid is only partially dissolved by 
heat and returns when the urine is cool. To determine the presence of 
albumose in such cases the urine must first be freed from albumin. The 
specimen to be examined, if concentrated, must be diluted with water, 
since albumose is insoluble in a concentrated saline solution. It is acidi- 
fied with acetic acid. One- sixth of its volume of a concentrated solution 
of common salt is added, and the mixture boiled and filtered while hot. 
The presence of albumose is indicated by an opacity or precipitate as the 
filtrate becomes cool. This result also takes place when a concentrated 
solution of ammonium sulphate is added. Such albumosuria or pro- 
peptonuria has been found in osteomalacia, bone tumors, scarlet fever, 
measles, pemphigus, and urticaria, and we have observed it in a case of 
niyxoedenia. Senator has repeatedly found albumosuria to precede and 
follow albuminuria, also to alternate with it. 



1006 



DISEASES OF THE UUrNAPY APPARATUS. 



According to Stadelmann's researches, peptone never occurs in fresh 
urine, although it is possible for it to be present in putrid albuminous 
urine, since peptone may arise from the action of putrefactive organisms 
on albumin. What is called peptonuria is apparently an albumosuria, 
due to the presence in the urine of the albumoses to be detected by 
Salkowskf s test. Such albumoses arise from the destruction of cells, 
especially pus- corpuscles, and, according to Senator, their appearance in 
the urine is indicative of the near approach of the crisis of pneumonia, 
and of the suppurative nature of an empyema, peritonitis, or meningitis. 
Salkowski's test is to be applied as follows. Filter the boiled urine in 
which albumin is precipitated and albumose is dissolved. Fifty cubic 
centimetres of this urine are acidified with five cubic centimetres of hydro- 
chloric acid, and a precipitate obtained with phosphomolybdic acid. The 
precipitate, heated for a few minutes, adheres to the bottom of the dish. 
The free fluid is poured off, and the precipitate, after having been washed 
with distilled water, is dissolved in five-tenths of a cubic centimetre of a 
dilute solution of caustic soda (specific gravity 1.16). A deep blue color 
is formed which becomes yellow when heat is applied, the more rapidly 
if a few more drops of the solution of caustic soda are added. After the 
fluid, poured into a test-tube, is cold, add, drop by drop, with shaking, 
a one per cent, or two per cent, solution of sulphate of copper. If 
" peptone" be present the fluid will become red. 

FIBRINURIA. 

Fibrin is rarely found in the urine except as a clot in hematuria and 
chyluria. The clots are usually present when the urine is passed, but 
may first appear after the urine has been voided. In severe inflamma- 
tion of the urinary tract the passage of the clots may be associated with 
renal colic and obstructed urination. Yon Jaksch records the occurrence 
of spiral membranes composed of fibrin and nucleoalbumin (mucin) as 
evidence of a membranous ureteritis analogous to membranous colitis. 

LITHURIA. URATURIA. URICACIDURIA. 

English writers, in particular, have attached a considerable" degree of 
importance to the presence in the urine of the brick- dust — later itious — 
sediment, consisting chiefly of sodium, potassium, and ammonium urates, 
and of uric acid. The precipitation of these constituents of the urine 
occurs under normal conditions in an acid concentrated urine, especially 
in cold weather. The pigmented amorphous "urates are easily dissolved 
by warming the urine, while the reddish crystals of uric acid suggest 
grains of pepper or sand, and sufficiently characteristic shapes are seen 
with the microscope. 

The frequent appearance of the brick- dust sediment in acute inflam- 
matory affections with profuse elimination of liquid from the skin or 
intestine, as in rheumatic fever, pneumonia, and gastro -enteritis, is well 



DISEASES OF THE KIDNEYS. 



1007 



known. Although an increased production of uric acid and urates is 
recognized as taking place in fever, it is not essential in the production 
of lithuria, since the latter is often found in healthy and vigorous indi- 
viduals. It is recognized that in gout an increased elimination of uric 
acid at times takes place, and that a deposition of urates takes place in 
various parts of the body, especially in the joints, although at the time 
of the deposition the excretion of uric acid may be diminished. The dis- 
covery of uric acid in the blood and lymph in such cases has led to the 
consideration of gout as the extreme illustration of a uric acid diathesis. 
In leukaemia there is also an increased elimination of uric acid, but with 
the exception of these two diseases it is doubtful whether there are any 
in which a persistent increase in the elimination of uric acid occurs. 

The association of various disturbances of digestion with symptoms 
of functional nervous disturbance, as easily induced exhaustion, irrita- 
bility, or depression, and headaches, with a brick- dust sediment, sand, or 
gravel, was attributed by Murchison to functional disorders of the liver 
resulting in the production of a disease, lithsemia, the conspicuous symp- 
tom of which was the lithuria or uraturia. Inasmuch as similar symp- 
toms occur in the absence of the brick- dust sediment, even in alkaline 
urine, either with the deposition of phosphates, phosphaturia, or with the 
abundant presence of calcium oxalate in the urine, oxaluria, and as the 
brick-dust sediment takes place under various physiological conditions, 
it is obvious that this sediment is not proof of an increased formation 
of uric acid or of a uric acid diathesis. There is no proof that lithuria 
is connected with disturbances in the function of the liver, and the use 
of the term lithsemia should not imply that the existing disturbances are 
in any way attributable to an excess of uric acid. 

OXALURIA. 

Crystals of calcium oxalate are to be found in the urine of healthy 
persons as well as in that of the sick. They may form in the urinary 
tract, or first appear after the urine has been voided, from the progres- 
sive decomposition of acid sodium phosphate, which is the most impor- 
tant agent in holding them in solution, and are easily to be recognized 
as the familiar octahedral or dumb-bell crystals. They are present only 
in acid urine, and Fiirbringer has shown that the number of crystals seen 
with the microscope does not indicate the quantity of oxalic acid present. 
Oxaluria becomes increased when certain articles of food, especially to- 
matoes and rhubarb, are taken. Its presence may alternate in the same 
case with that of uric acid and the urates in the urine. Oxaluria is of 
frequent occurrence in saccharine diabetes, in which it may be followed 
by glycosuria. Its association with jaundice, spermatorrhoea, digestive 
disturbances, and neurasthenia is to be recognized. 

As in lithaeinia, the combination of digestive disturbances, especially 
flatulence, with mental and bodily fatigue on slight exertion, listlessness, 



1008 



DISEASES OF THE URINARY APPARATUS. 



headache, wakefulness, mental depression, backache, and crystals of calcic 
oxalate in the urine, is regarded as characteristic of an oxalic acid diath- 
esis and classified as oxaluria. As has been stated concerning lithsemia, 
the origin of oxalic acid in the body is obscure. The methods of deter- 
mining its absolute increase belong rather to the laboratory than to the 
bedside, and the symptoms regarded as due to its presence in excess occur 
independently of an oxaluria and of any special chemical modification 
in the composition of the urine. 

The escape of excessive quantities of crystals of calcic oxalate may 
mechanically irritate the urinary passages and produce pain in the ureter 
or the urethra. An occasional red blood- corpuscle may be found in the 
urine under such circumstances. 

The relation of oxalates to conditions of the nervous system is, from 
a physiological and a pathological stand-point, extremely obscure. In 
ordinary melancholia there is commonly a severe oxaluria, which is with 
difficulty remedied, and in which the mental symptoms do not improve 
with lessening or disappearance of the oxalic acid. On the other hand, 
there are cases especially occurring in young men in which malaise and 
great repugnance to mental and bodily exercise are associated with 
marked depression of spirits, without other pronounced symptoms except 
the presence of oxalates in the urine, and in which nitrohydrochloric 
acid acts as a specific, causing the various symptoms to disappear pari 
passu with the oxalates. Exercise, regulation of the diet, and the avoid- 
ance of sweets and indigestible materials may be of service in these cases ; 
but nitrohydrochloric acid is the main element in effecting a cure. From 
five to seven drops of the freshly prepared acid should be given three 
times a day. 

PHOSPHATURIA. 

Sodium and potassium phosphates and calcium and magnesium phos- 
phates are precipitated in a neutral or alkaline urine, and the ammonio- 
magnesic or triple phosphates are added if an ammoniacal fermentation 
takes place. This precipitation may occur within the body if alkaline 
salts are abundant in the food or drink or are used as medicines. The 
appearance of the crystals is sufficiently characteristic for diagnostic 
purposes, and the addition of an acid causes them to disappear. The 
occurrence of a phosphatic sediment is no evidence of an absolute in- 
crease of the phosphoric acid in the urine, to which alone the term 
phosphaturia should be applied, and which, like the absolute increase 
of oxalic acid, must be determined in the laboratory. An increased 
elimination of phosphates takes place in meningitis, in epileptic con- 
vulsions, in saccharine diabetes, and in leukaemia. In diabetes, phos- 
phaturia, like oxaluria, may alternate with glycosuria. Tessier has 
applied the term phosphatic diabetes to a class of cases in which phos- 
phaturia and polyuria are combined with loss of flesh and strength. 

Persistent alkalinity of the urine with a phosphatic sediment is fre- 



DISEASES OF THE KIDNEYS. 1009 

quently observed in persons suffering from indigestion, especially the 
variety due to a deficiency of hydrochloric acid. Such patients complain 
of mental and physical weakness, backache, and sexual irregularities, and 
are conspicuously neurasthenic or hypochondriacal. They frequently 
regard the sediment as evidence of inflammation of the bladder or of 
spermatorrhoea, and, through ignorance of its nature, often become the 
victims of charlatans. 

In cei'tain cases of neurasthenia there is an extraordinary increase 
in the elimination of the phosphates, but we know of no specific medi- 
cation especially adapted to such cases. Sexual intercourse should be 
altogether or in great part interdicted. When there is danger of the 
formation of phosphatic calculi, boric or benzoic acid should be admin- 
istered, as urine deposits phosphates much less readily when acid than 
when alkaline. 

CYSTINURIA. 

Cystin rarely occurs in the urine, and is seen as hexagonal plates, to 
be recognized by the microscope. Cystinuria is found more often in 
young persons, at times in several members of the same family, and 
has been observed by Ebstein combined with albuminuria, both of which 
simultaneously disappeared in acute rheumatism. Its presence is incon- 
stant, and the quantity eliminated is variable. The clinical importance 
of this condition is due txTthe fact that a characteristic calculus may 
be formed, to be recognized by its smooth, yellow, translucent appear- 
ance and crystalline fracture. The presence of sulphur in cystin and 
in the taurin of the bile, and the occurrence of a case of cystinuria with 
chronic biliary obstruction, have suggested that cystinuria may be due 
to disturbance of the function of the liver, a view disproved by the ob- 
servation that in cystinuria there is an increased elimination of sulphur 
in the bile. Baumann and Udranszky have found diamines ( cadaver ine, 
putrescine), which, according to Brieger, are due to specific bacteria, in 
the urine and in the faeces in cystinuria, but not in normal faeces : hence 
they suggest that diaminuria and cystinuria may be due to the same 
cause. 

GLYCOSURIA. MELITURIA. 

These terms are applied to the presence of grape sugar, glucose, in the 
urine. Other varieties of sugar, as milk sugar, muscle sugar, fruit sugar, 
and pentose rarely, may be found. Baumann states that traces of sugar 
are present in normal urine, and a distinction is hence to be drawn, 
as in albuminuria, between a physiological and a pathological glycosuria. 
Usually the quantity of sugar found under physiological conditions is so 
small that its presence is to be recognized only by the most delicate tests. 
A physiological glycosuria becomes important only when considerable 
quantities of sugar recognizable by ordinary tests are found in the urine. 
It may result from the excessive use of sugar, three or four ounces daily, 
and ceases with the removal of the cause, alimentary glycosuria. Lacto- 

64 



1010 



DISEASES OF THE URINARY APPARATUS. 



suria, milk sugar in the urine, has been repeatedly found in pregnancy, 
especially after childbirth, when abundant milk is retained in the breast. 
Such urine does not react to the fermentation-test, although polarizing 
light to the right. 

Pathological glycosuria may be divided into the transitory and per- 
manent varieties. The former occurs as a rare complication of the disease 
in which it is present, and has been observed in cerebral hemorrhage, 
in cerebro- spinal meningitis, and in disease of the brain in the vicinity 
of the fourth ventricle, in injuries to the head, according to Higgins 
and Ogden, in infectious diseases, as typhoid and malarial fevers, cholera, 
diphtheria, influenza, and scarlet fever, in gout, and in diseases of the 
heart, lungs, and liver, especially in fibrous hepatitis. It has also been 
observed in poisoning from opium, chloral, and carbonic oxide gas, and 
may be experimentally produced in a variety of ways, — e.g., by punc- 
ture of the fourth ventricle, by intravenous injection of salt solutions, or 
by poisoning with amyl nitrite or phloridzin. Permanent glycosuria 
is the essential characteristic of diabetes mellitus, in which disease it 
may be found in the absence of other symptoms, the quantity of sugar 
becoming gradually increased on a saccharine and starchy diet. 

The tests in common use for the detection of glucose in the urine are 
those of Moore, Trommer, Fehling, and the fermentation-test. Albumin is 
first to be sought for, and, if present, eliminated by boiling and filtration. 

Moore 7 s Test. — Mix with the suspected urine in a test-tube one-third 
of its volume of liquor potassse. A precipitate of earthy phosphates 
takes place. Heat the upper portion of the fluid, which becomes of a 
dark-brown color if sugar is present ; in normal urine a light-brown 
color, attributed to the presence of "mucin," frequently develops. On 
the addition of a drop or two of strong sulphuric acid to the brown solu- 
tion when cold, the odor of burned sugar is produced if the brown color 
is due to the presence of glucose. This test is only of relative value, since 
a brown color is often produced in the absence of glucose, and small 
quantities of the latter may escape recognition. 

Trommels Test. — Mix with the suspected urine in a test-tube one- 
third of its volume of liquor potassae. Add a few drops of a solution 
of cupric sulphate (1 to 10). A bluish-green, flocculent precipitate of 
hydrated copper oxide forms. If sugar is present the precipitate is 
dissolved on shaking, and the fluid becomes dark blue. Drops of the 
copper solution are to be added as long as the precipitate is dissolved. 
The mixture is then heated, and the rapid formation of a reddish -yellow 
precipitate of cuprous oxide before the boiling point is reached indicates 
the presence of glucose. This test is of no value unless more than one -half 
of one per cent, of glucose is present in the urine. The solution of cupric 
sulphate should be added drop by drop, since an excess of this reagent 
may prevent its reduction. The cupric oxide may also be reduced in 
concentrated urine containing a large quantity of uric acid and urates, 



DISEASES OF THE KIDNEYS. 



1011 



in the presence of creatinine, alkapton, brenzkatechin, hydrochinone, 
mucin, or bilirubin, and after the use of benzoic acid, salicylic acid, 
glycerin, chloral, phenacetin, morphine, or chloroform. Such sources of 
error may be overcome by diluting the concentrated urine with three or 
four times its volume of water ; by shaking the test-tube containing the 
pigmented urine in which a pinch of animal charcoal has been added, 
filtering the specimen, and testing the nitrate ; and by avoiding the use 
of the above-mentioned drugs. 

Fehling's Test. — This test also depends upon the reduction of copper 
which is dissolved in Eochelle salt. Fehling's solution is best made by 
the immediate mixture of solutions of its ingredients separately preserved. 
For this purpose 34.64 grammes of cupric sulphate are to be dissolved 
in 500 cubic centimetres of water and kept in a bottle. In another bottle 
is to be preserved a solution of 175 grammes of Eochelle salt in 100 cubic 
centimetres of caustic soda, specific gravity 1.34, and dissolved in 500 
cubic centimetres of water. A mixture of equal quantities of these fluids 
is Fehlings solution. A drachm of this solution is to be poured into a 
test-tube, and two or three times as much water should be added if the 
presence of a high specific gravity of the urine does not suggest a con- 
siderable quantity of glucose. The solution is boiled to test its efficiency, 
since in old solutions of Eochelle salt products of decomposition may 
arise which reduce the copper. If the absence of such products is thus 
shown, an equal quantity of urine is added, the mixture heated, and a 
reddish -yellow precipitate of cuprous oxide takes place when glucose is 
present. The percentage of glucose may also be determined by the use 
of Fehling's solution, 10 cubic centimetres of which correspond to 0.05 
gramme of glucose, and the necessary apparatus, solutions, and directions 
combined for this purpose may be bought. 

Fermentation- Test. — Sources of error arising from the reduction of 
copper by other agents than glucose may be avoided by the fermentation 
of the urine, which has a further advantage in permitting a ready approx- 
imate determination of the percentage of glucose when it is above one- 
tenth per cent. This constituent alone in the urine causes alcoholic fer- 
mentation. About four ounces of urine are poured into a bottle, half 
a cake of finely subdivided yeast is added, and the mixture is placed in 
a room of ordinary temperature until the fermentation caused by the 
glucose is ended, usually in the course of twenty-four hours. The specific 
gravity of the fluid is then compared with that of another sample of the 
urine which has been set aside and exposed to the same circumstances 
as the fermented urine, excepting the addition of yeast. According to 
Eoberts, each degree of density lost corresponds to one grain of glucose in 
the ounce of urine, — i.e., 0.219 per cent. Hence the percentage of sugar 
present is ascertained by multiplying the difference between the specific 
gravities by 0.219. The simplicity, convenience, and practical accuracy 
of this test make it generally applicable. 



1012 



DISEASES OF THE URINARY APPARATUS. 



ACETONURIA. DIACETICACIDURIA. 

Although traces of acetone may occur in normal urine, its presence 
in considerable quantities is the result of pathological conditions. The 
accurate determination of the quantity requires distillation of the urine. 
For practical purposes when the question concerns an increased quantity 
Legal' s test is sufficient. A few drops of a moderately concentrated, 
freshly prepared solution of sodium nitroprussicle and a small quantity 
of the official solution of potash or soda are added to ten cubic centi- 
metres of urine. If acetone is present a red color is produced, which 
quickly fades and becomes violet or purple if acetic acid is added. 
Acetone results from the destruction of the albumin of the food or of 
that of the tissues. Its excessive formation takes place in fevers, in 
diabetes mellitus, in wasting diseases, in peritonitis, in periodical vomit- 
ing, in certain nervous affections, as hysteria, convulsions, coma, cere- 
bral plumbism, gastric crises of tabes, in certain auto-intoxications and 
chronic opium poisoning, and in connection with certain cases of cancer. 
It is not known that acetone produces injurious effects, although Cantani 
considers that mild or severe disturbances of the nervous system may 
result from excessive acetone in the blood. Although its occurrence in 
diabetes takes place in the advanced stage of this affection, the prognosis 
is unaffected by its presence. Its transformation into diacetic acid is 
associated with the symptoms of toxaemia. 

Diacetic acid, aceto-acetic acid, does not occur in normal urine, but, 
when found, is associated with the presence of acetone. It is to be recog- 
nized by the cautious addition of a moderately concentrated solution of 
ferric chloride. If phosphates are precipitated, the urine should be 
filtered and the iron added anew. If the urine becomes of a claret color 
which fades or disappears when the urine is boiled, the presence of di- 
acetic acid is indicated. Diaceturia occurs in fevers, in diabetes, and in 
certain cases of infantile convulsions and wasting affections. In adults 
it is of prognostic importance, since the patients concerned, whether 
febrile or diabetic, not infrequently die comatose, the symptoms resem- 
bling those seen in diabetic coma : in children it has no especial sig- 
nificance. 

LIPACIDURIA. 

Traces of volatile fatty acids, acetic, butyric, formic, and propionic 
acids, are to be found in normal urine. It is probable that they, like 
acetone, are due to albuminous oxidation. Their increased presence in 
fever, fibrous hepatitis, cancer of the liver, gall-stones, and diabetes 
mellitus is explained by the occurrence of an extensive albuminous 
destruction in these affections. It is possible that an excess of these 
acids may be formed in the intestine in abnormal digestion and be 
eliminated with the urine. Like acetonuria, lipaciduria has no clinical 
significance. 



DISEASES OF THE KIDNEYS. 



1013 



HYDROTHIONURIA. 

Brief mention may be made of the rare occurrence in the urine of 
sulphuretted hydrogen. Its presence is usually indicative of an abnor- 
mal communication between the intestine and the urinary tract, but, the 
possibility of auto-intoxication by the absorption of sulphuretted hydro- 
gen from the intestine being recognized, it is conceivable that this gas 
may be excreted with the constituents of the urine, or that it may enter 
the bladder from the intestine by diffusion through the intervening tis- 
sues. The significance of hydrothionuria is at present merely suggestive. 

CASTS. 

Among the most important of the morphological constituents of the 
urine are casts of the urinary tubules. They differ in composition and 
appearance, and are always evidence of a pathological condition, although 
their diagnostic and their prognostic significance vary within wide limits. 
They are present in the urine in various quantities, are usually, although 
not necessarily, associated with albuminuria, and. are most easily found, 
when few, by permitting the urine to stand for several hours in a coni- 
cal glass receptacle, that the casts may settle in a limited place. The 
use of the centrifuge permits the speedy isolation of casts even when few 
in number. The rapid growth of bacteria in the urine makes it de- 
sirable, if the specimen is allowed to stand for many hours, to add an 
antiseptic, as thymol, which neither coagulates albumin nor precipitates 
urinary salts. Hyaline casts are made more conspicuous when stained, 
and for this purpose aniline colors, carmine, hematoxylin, or an aqueous 
solution of iodine may be employed. 

The basis of all casts, with the exception of certain epithelial and 
blood casts, is a hyaline material, which is probably of albuminous ori- 
gin, although, according to Knoll, it is not identical with any known form 
of albumin. It is probably derived from the albumin of the blood, and 
is either passed through the Malpighian capillaries or is secreted by the 
renal epithelium, or, being transuded into the latter, is then transformed 
into the cast by the degeneration, death, and fusion of the epithelial 
cells. The combination of various materials with this hyaline substance 
gives rise to modifications in the appearance of the cast, to which special 
terms are given. 

Hyaline casts are long or short, broad or narrow, homogeneous, pale 
bodies, in the form of cylinders, usually rounded at one end, and often 
to be recognized only by careful adjustment of the reflecting mirror or 
by staining. Thomas applies the term cyUndroids to hyaline casts, which 
are unusually long, flattened, often streaked, bent, and serpentine, one 
end terminating in a point, the other rounded or translucent, broken, 
sometimes bifurcated or fused with the typical hyaline cast, with which, 
according to Rovida, it is identical in chemical composition. x\ dis- 
tinction between the cylindroid and the " mucous 11 cast is not apparent. 



1014 



DISEASES OF THE URINARY APPARATUS. 



Waxy casts, which, also present a homogeneous appearance, are usually- 
short and broad, yellow and glistening. They sometimes give the amy- 
loid reaction, although their presence is in no way suggestive of amyloid 
disease of the kidney. It is probable that they are hyaline casts which 
have been long retained in the renal tubules. Epithelial casts occur in two 
varieties : the one, rare, represents the desquamation of a portion of the 
coherent epithelial lining of the straight tubules ; the other, the ordinary 
epithelial cast, is formed by the agglutination of desquamated renal epi- 
thelium or of leukocytes within or upon the surface of the hyaline cast. 
Granular casts occur when granules of various origin are united by the 
hyaline material, and a subdivision is made between fine granular and 
coarse granular casts. Such granules may be albuminoid, resulting from 
a transformation of portions of the hyaline cast or from the disintegra- 
tion of renal epithelium, leukocytes, or red blood- corpuscles, from a fatty 
degeneration of renal epithelium and leukocytes, from the deposition of 
urinary salts, sometimes as crystals (calcic oxalate), or from bacteria. 
Fatty casts are so designated when the granules are sufficiently large to 
present the optical appearances of fat. The fat- drops result from the 
degeneration of cells, and may be present within the adherent cell, or 
may appear as irregularly grouped, isolated drops of various size. Acic- 
ular crystals may be formed from the fat and project as spines from the 
surface of the cast. Blood-casts occur in two varieties : the one is due to 
the clotting of blood in the renal tubules ; the other to the combination 
of red blood- corpuscles and the hyaline basis of the various casts. The 
red blood-corpuscles may be colored or decolorized, and homogeneous 
brown casts are at times to be found, the color of which is probably 
blood-pigment. In hemoglobinuria colored casts are present, appar- 
ently due in considerable part to agglutinated fragments of hsemoglobin. 

In general, hyaline casts are associated with albuminuria, although 
they may be found when albumin is absent, as in cholera, jaundice, and 
poisoning with sulphuric acid or alcohol. They may be temporarily 
absent when albuminuria is present, as in fibrous nephritis and amyloid 
degeneration, or permanently so in chyluria. Although they are indica- 
tive of a pathological condition of the kidney, they do not necessarily 
indicate a diseased state of the individual, since they disappear with a 
transitory albuminuria, and, as F. 0. Shattuck has shown, they may be 
present for years, even combined with albuminuria, in persons in whom 
there is no other evidence of renal disease or of irritation of the kidneys. 
They may be overlooked, or found only on prolonged search, or, according 
to Sehrwald, be digested by the presence of pepsin in acid urine. The 
cylindroids, like the hyaline casts, are not characteristic of disease of the 
kidneys, since they may be seen in normal urine as well as in that of 
passive congestion of the kidney, nephritis, and cystitis. The presence 
of fat- drops and granular corpuscles is indicative of a fatty degeneration 
of cells, and is especially significant of a chronic parenchymatous or dif- 



DISEASES OF THE KIDNEYS. 



1015 



fuse nephritis. Ked blood- corpuscles may be present in both acute and 
chronic nephritis as well as in renal hemorrhage. Bacterial casts in urine 
relatively free from bacteria are suggestive of an infectious pyelonephritis 
or septic embolism of the kidney, but bacteria growing in stale urine 
readily adhere to the surface of casts, and are then merely evidence of 
decomposition of the urine. 

PYURIA. 

The presence of pus- corpuscles in the urine produces an albuminuria, 
but the latter may be due to the pus- corpuscles alone or to a combined 
nephritis. A few pus- corpuscles in the urine may result from a nephritis, 
and many pus-corpuscles from sources outside the kidney may be asso- 
ciated with a nephritis. It is, therefore, important to ascertain to what ex- 
tent the accompanying albuminuria may depend upon the presence of the 
pus-corpuscles. According to Salkowski and Leube, two per cent, of pus 
in the urine corresponds to one-tenth per cent, of albumin. The percent- 
age of albumin alone does not determine the dependence of its origin 
upon pus, since moderate pyuria, two per cent, of pus, may be associated 
with considerable albumin in the urine. If on boiling the urine a moder- 
ate precipitate of albumin, one-twentieth to one-twenty-fifth of the volume 
of the urine, is formed, its exclusive origin from pus is to be inferred if 
several pus- corpuscles are found in each drop of the shaken urine. In 
two per cent, of pus with one-tenth per cent, of albumin there are ten to 
fifteen pus- corpuscles in each microscopical field. Fewer pus- corpuscles 
than these with this amount of albumin suggest a simultaneous nephritis. 
With one-fifth per cent, of pus there is merely a trace of albumin, and 
if pus-corpuscles are not present in every field chronic nephritis is to be 
suspected, and casts should be sought for by repeated examinations if 
necessary. Pyuria may be caused by urethritis, cystitis, pyelitis, tuber- 
culosis, or abscess of the kidney, and by the evacuation into the urinary 
tract of a perinephric or peritonitic abscess or an abscess of the abdom- 
inal wall. The presence of epithelial casts and pus-corpuscles is sug- 
gestive of a pyelonephritis, while characteristic bacilli are indicative of 
renal tuberculosis. 

UREMIA. 

General Symptomatology. — When the elimination of the urinary 
constituents is prevented for some time, their accumulation in the blood 
results in a toxaemia to which the term uraemia is applied. Chemical and 
experimental investigations have been unsuccessful in demonstrating that 
this toxaemia is due to any especial component of the urine. It results 
from prolonged interference with the normal secretion of urine, whether 
due to disease of the kidney or to obstruction to the outflow of urine. 
Although the symptoms of uraemia are usually preceded by a diminution 
in the quantity of urine, oliguria, perhaps terminating in complete sup- 
pression of this secretion, anuria, uraemic symptoms may be present and 



1016 DISEASES OF THE URINARY APPARATUS. 

the quantity of urine be normal although its specific gravity is much 
diminished. 

The disturbances from uraemia affect particularly the nervous system 
and the digestive apparatus, and according to the rapidity or slowness 
of their development a distinction is drawn between acute and chronic 
uraemia, although there is no sharply defined line of demarcation, and the 
violent symptoms of acute uraemia may develop in a patient who has 
hitherto shown only the milder symptoms of chronic uraemia. The ner- 
vous symptoms of acute uraemia are usually severe, may be sudden and 
unexpected, often intermittent, or may be preceded by those of chronic 
uraemia. In the latter case a mild headache becomes intense ; wake- 
fulness, restlessness, or depression becomes delirium, perhaps mania or 
melancholia. Irregular twitchings and feelings of exhaustion may be 
followed by convulsions of an epileptiform character, or coma (uraemic 
apoplexy) may occur, in which the patient dies or from which he may 
rally and remain for a while comparatively comfortable. Localized ner- 
vous disturbances, also, suddenly occur, especially affecting the motor 
nerves, either as muscular tremors or cramps or as pareses or paralyses. 
Hemiplegia at times appears, with or without aphasia, disturbances 
of hearing, either deafness or the appreciation of abnormal sounds, 
take place, and amaurosis is frequent. The frequently brief duration of 
these general and localized symptoms suggests as their probable explana- 
tion temporary disturbances of circulation in the areas concerned. The 
digestive disturbances characteristic of acute uraemia are manifested 
by persistent vomiting or diarrhoea. The irritation of the bowels is 
sometimes associated with tenesmus and bloody stools suggestive of 
dysentery, and in such case a diphtheritic inflammation of the colon or 
the ileum has been found after death. 

The symptoms of chronic uraemia may be so mild and their develop- 
ment so gradual that they are often overlooked until the sudden outbreak 
of the acute manifestations. It is then learned that the patient has been 
disturbed by headaches or peripheral neuralgia without especial cause, or 
has been either restless and wakeful or fatigued and listless. There may 
have been slight muscular tremor or spasm, and obstinate itching of the 
skin is not infrequent. It is, as a rule, the digestive disturbances which 
cause the patient to seek for medical advice. These, in particular, are 
loss of appetite, nausea, and vomiting. The patient may complain of dry- 
ness of the mouth and difficulty of swallowing, while the breath may have 
an odor suggesting that of urine. The nausea and vomiting are frequently 
independent of the quality or the quantity of food taken, and often occur 
when the stomach is empty. The occurrence of diarrhoea without assign- 
able cause is more often significant of acute than of chronic uraemia. 

Disturbances of respiration are frequent in chronic nephritis, and are 
usually spoken of as urcemic asthma. The difficulty of respiration varies 
in character, at times being slight, although more or less constant and 



DISEASES OF THE KIDNEYS. 



1017 



aggravated by exertion ; again, there are paroxysms of dyspnoea without 
obvious exciting cause, resembling attacks of asthma. Finally, the respi- 
ration may present the Cheyne- Stokes character. Although the dyspnoea 
is spoken of as uraeniic, it is questionable whether uraemia is the cause, 
since the other symptoms of uraemia are not necessarily associated. Its 
characteristics are those of a cardiac dyspnoea, and corresponding lesions 
of the heart and the blood-vessels are frequently found. In many cases 
oedema of the lungs acts as a physical cause of the disturbed respiration. 

Diagnosis. — An examination of the urine, when possible, may suffi.ce 
to establish the diagnosis of uraemia. This condition may be suspected 
as the cause of the severe symptoms, if there is a history of oliguria and 
especially of anuria. It is to be remembered, however, that cerebral 
hemorrrhage is of frequent occurrence in chronic nephritis, and that a 
complicating organic lesion of the brain may serve as the cause of the 
paralysis in any disease of the kidney. The examination of the urine is 
especially important in those cases of possible acute uraemia in which a 
similar grouping of symptoms may occur in the absence of organic disease 
of the brain, as in epilepsy, alcoholic intoxication, and opium poisoning. 
Time also may be necessary for the formation of the diagnosis, since 
temporary albuminuria may follow an epileptic fit or a cerebral hemor- 
rhage, and an alcoholic odor of the breath or a contracted pupil does not 
exclude the possibility that an excess of alcohol or of opium has been 
taken by a sufferer from nephritis. In the absence of an obvious cause 
for an unexpected attack of persistent vomiting and diarrhoea, the exam- 
ination of the urine and the history of oliguria may show its uraemic 
character. The routine examination of the urine becomes important in 
all cases of headache and digestive disturbance of obscure origin, and 
may make the diagnosis clear in those cases in which mild delirium, 
cerebral torpor, or stupor with elevation of temperature might be re- 
garded as indicative of a meningitis. Indeed, the possible manifestations 
of uraemia are so manifold, and often so obscure, that the urine of every 
patient suffering from chronic disease of not entirely patent nature should 
be carefully studied. 

Prognosis. — The significance of uraemic symptoms is dependent in 
part upon their cause and in part upon their nature. If the former is 
removable, as a calculus, the symptoms may permanently disappear. 
The occurrence of symptoms of acute uraemia is usually indicative of 
early death, although in rare instances a severe attack may be followed 
by several years of freedom. The milder symptoms of chronic uraemia 
may exist for years and the individual consider himself in fair health. 
In such persons, in particular, the occurrence of convulsions or coma 
usually points towards an early fatal termination. In the estimation of 
the significance of the symptoms of chronic uraemia valuable informa- 
tion is to be derived from the occasional measurement of the total quanl it y 
of urine passed in the twenty-four hours and the determination of the 



1018 



DISEASES OF THE URINARY APPARATUS. 



amount of urea eliminated. Although, as has been stated, the symptoms 
of uraemia are not dependent upon any especial urinary constituent, the 
determination of the total quantity of urea eliminated in the twenty-four 
hours affords a valuable test of the principal function of the kidney. 
Normally the daily elimination of urine is in the vicinity of three pints, 
or fifteen hundred cubic centimetres, and the amount of urea in the 
vicinity of six hundred grains, or forty grammes. For clinical purposes 
the estimation of the total amount of urea passed in the twenty-four 
hours is most easily accomplished by the hypobromite method, with the 
apparatus of either Doremus or Squibb. 

RENAL DROPSY. 

One of the most important symptoms of renal disease is dropsy, 
although it may be absent in severe disease of the kidneys, and when 
present may vary in degree within wide limits. It represents the result 
of the transudation of the liquid portion of the blood through the walls 
of the blood-vessels. Since such a transudation through the walls of 
normal vessels takes place to only a limited extent, Cohnheim consid- 
ered that an increased porosity was caused by the disease of the kidney. 
According to him, a toxaemia results from the insufficient elimination of 
the products of tissue-metamorphosis, in consequence of which the nutri- 
tion of the vascular wall becomes disturbed. Senator maintains that the 
glomerular capillaries are diseased when dropsy exists, although they 
may be affected and dropsy be absent. Eenal dropsy is most frequently 
found in certain varieties of acute nephritis, in chronic diffuse nephritis, 
and in amyloid degeneration. Its occurrence in other varieties of renal 
disease is mechanical, due to a weakening of the heart's action and a 
consequent passive congestion. It is usually first observed in the face, 
especially as a puffiness of the eyelids, and at the end of the day is more 
likely to be found about the ankles. Eventually the subcutaneous tissue 
throughout the body may become involved, and finally the serous cavi- 
ties and the lungs. The degree of dropsy is often intimately connected 
with the secretion of urine, being greater when the latter is less, and vice 
versa, a change in relation frequently taking place at short intervals. As 
a rule, the dropsy is more considerable when the quantity of albumin is 
large. Extreme degrees of dropsy produce cracks in the skin, hydro- 
thorax, hydropericardium, ascites, oedema of the lungs and larynx, and 
intra-cranial oedema. The skin is then in danger of becoming infected, 
disturbances of respiration and circulation result from the fluid in the 
lungs, pleurae, pericardium, and peritoneum, while suffocation is threat- 
ened from oedema of the larynx. The intra-cranial oedema may be a 
mechanical cause of many of the symptoms of uraemia already mentioned. 

ALTERATIONS OF THE HEART AND BLOOD-VESSELS. 

Alterations of the circulatory apparatus in nephritis are of such 
frequency as to require especial consideration. The most important of 



DISEASES OF THE KIDNEYS. 



1019 



these lesions is hypertrophy of the heart, in particular of the left ventricle, 
without valvular disease, and is so constantly present in fibrous nephritis 
as to be of diagnostic importance. Although the extreme degrees of 
hypertrophy of the left ventricle are found in the latter affection, lesser 
degrees may be present both in acute and in chronic diffuse nephritis. 
Senator has called attention to the fact that hypertrophy without dilata- 
tion is the rule in the atrophic form of fibrous nephritis, while hypertrophy 
with dilatation occurs in other varieties of nephritis. 

The arterial change which is especially noteworthy is the thicken- 
ing of the wall, especially of the smaller arteries, the arterio -sclerosis, 
to which Gull and Sutton first called attention under the term arterio- 
capillary fibrosis. All the coats are thickened, and the arteries in various 
parts of the body are affected. It has been suggested that the vascular 
changes were the cause of the cardiac hypertrophy, and that the nephritis 
occasioned both. On the contrary, Gull and Sutton regarded the disease 
of the kidney as dependent upon the vascular changes. The former view 
prevails at the present time, although not free from objection. A pulse 
of high tension is often met with in the early life of individuals who pre- 
sent later the evidence of nephritis, and Johnson advanced the view that 
in chronic nephritis the blood becomes charged with products of tissue- 
metamorphosis which should have been eliminated by the kidney. He 
assumed that such altered blood caused contraction of the smaller arteries 
and thus produced the hypertrophy. The objection to this theory is the 
fact that hypertrophy of the heart is most constant and extreme in fibrous 
atrophy of the kidney, in the genuine form of which the elimination of the 
products of tissue -metamorphosis in the urine is not diminished except 
in the later stages. Senator admits Johnson's explanation for the occur- 
rence of cardiac hypertrophy in all forms of nephritis except for the 
atrophied kidney, the genuine form of which is probably caused by a 
toxic condition of the blood acting simultaneously upon the kidneys 
and the blood-vessels, resulting in hypertrophy. In the arterio -sclerotic 
atrophied kidney both the cardiac hypertrophy and the renal atrophy 
may be attributable to the sclerosis of the blood-vessels. 

CONGESTION OF THE KIDNEY. 

Active and passive congestions of the kidney are to be discriminated, 
the former representing the presence of an increased quantity of arterial 
blood in the kidney, the latter due to the presence of an excessive quantity 
of blood in the renal veins. Arterial congestion of the kidneys occurs as 
the result of the presence in the kidney of irritants, and is of especial 
significance in connection with the production of inflammation. Extir- 
pation of one kidney usually causes arterial congestion of the other. An 
arterial congestion of the kidneys is assumed in diabetes in both the in- 
sipid and the glycosuric variety, and in affections of the nervous system 
in which polyuria occurs. Its temporary occurrence is probable after 



1020 



DISEASES OF THE URINARY APPARATUS. 



exposure to cold, or when excessive quantities of fluid are taken into 
the stomach and largely eliminated by the kidneys. The effects of an 
irritative or inflammatory arterial congestion of the kidney are described 
in the article on nephritis. The immediate effect of the removal of 
one kidney upon the function of that remaining is a diminution in the 
flow of urine, which may contain albumin and red blood- corpuscles. 
Other causes of arterial congestion produce an increased flow of urine 
in which neither blood nor albumin is necessarily present. 

Passive Congestion. 
Etiology. — The causes of passive congestion of the kidney are 
either general or local. The former are to be found in diseases of the 
heart, lungs, and pleura, obstructing the flow of blood through these 
organs. The latter are conditions obstructing the flow of blood through 
the inferior vena cava or through one or both renal veins, whether from 
tumors, thrombi, or cicatricial stenoses in the vicinity, or from tumors or 
fluid in the abdominal cavity. Thrombosis of the inferior vena cava may 
also produce passive congestion of the kidneys. The effect of these causes 
is limited by the establishment of an efficient collateral venous circulation 
and by the heart's action. If the former occurs there may be little or no 
disturbance, but if, as usual, there is an insufficient compensatory circu- 
lation and the heart's action is weakened, the effect is essentially the same 
as when disease of the heart or of the lungs acts as the cause of the venous 
congestion. 

Mobbid Anatomy. — Long-continued obstruction to the outflow of 
venous blood from the kidneys produces a moderate diminution in the 
size of the organ following a previous state of enlargement, increased 
density, and a bluish-gray color, to which the term cyanotic induration 
is applied. The longer the obstruction is continued the more likely is 
the atrophied kidney to become pale, and to have the capsule adherent 
in places, with some of the Malpighian bodies obliterated, a condition 
representing a slight degree of granular atrophy. On microscopical 
examination casts and blood-pigment are found, also fat-drops in small 
quantity in the epithelium of the convoluted tubes. If thrombosis of 
the renal vein is a cause of the congestion, the kidney becomes greatly 
enlarged and is engorged with blood, and the microscope shows a necrosis 
of the epithelium. 

Symptoms. — The disturbances arising from the obstructed circulation 
in the kidney are so overshadowed by those produced elsewhere that the 
renal condition can be diagnosticated only by the examination of the 
urine. This secretion is acid, diminished in quantity, high-colored, its 
specific gravity in the vicinity of 1025, and there is a small quantity, 
usually less than one-eighth per cent., of albumin. A few hyaline casts 
and occasional red blood- corpuscles and leukocytes are to be found. A 
brick- dust sediment readily forms when the urine is allowed to stand, 



DISEASES OF THE KIDNEYS. 



1021 



disappearing when liquor potassae is added or the urine is heated. The 
formation of the sediment is due to the concentration of the urine, and 
not to an increase of urea and urates. In the stage of extreme atrophy 
the specific gravity may be as low as 1010. 

Diagnosis. — Passive congestion of the kidney is to be inferred from 
the evidence of the presence of the above-mentioned causes, and is to be 
diagnosticated by the recognition of the described characteristics of the 
urine. 

Prognosis. — The prognosis depends upon the cause, which usually 
permits merely temporary improvement, and the treatment is that of the 
basal condition. 

THROMBOSIS AND EMBOLISM. 

The occurrence of thrombosis of the renal vein has already been 
mentioned in connection with passive congestion of the kidney. Throm- 
bosis of the renal artery is rare, while embolism is of sufficient frequency 
to be of practical importance. 

Etiology. — The emboli, as a rule, arise in the left ventricle or in the 
aorta from parietal thrombi, and produce mechanical disturbances, to 
which infectious results are added if the emboli contain bacteria. 

Morbid Anatomy. — The extent of the mechanical disturbances re- 
sulting from embolism of the renal artery is dependent upon the size 
of the vessel obstructed. An ischsemic necrosis occurs in the region 
supplied by the obstructed vessel, appearing as an irregular mass of an 
opaque grayish- white or reddish-gray color surrounded by a dark-red 
zone. The tubular epithelium is in a condition of necrosis. Fat- drops 
eventually make their appearance, and the dead portion of the kidney 
becomes absorbed, being replaced by a scar adherent to the capsule of the 
kidney and often containing blood-pigment. If pyogenic bacteria are 
present in the embolus, an abscess results. 

Symptoms. — Embolism of the renal artery has no characteristic symp- 
toms, although in some cases sudden and unexpected pain in the region 
of the kidney has occurred, followed by the presence of blood in the 
urine. 

Diagnosis. — The diagnosis is based upon the concurrence of the above 
symptoms, or upon the occurrence of sudden hematuria alone in the 
urine of a person suffering from disease of the heart or of the aorta in 
which embolism is likely to take place. 

Treatment. — The treatment must be largely symptomatic, having 
for its special object lessening of the irritation of the kidney. Absolute 
rest in bed, uniform temperature, warm clothing, and careful nursing 
should be insisted upon ; the food should be restricted to milk, with, in 
feeble cases, eggs and small amounts of farinaceous food. Any diuretics 
used should be of the mildest character, and hseinaturia, if it occurs, 
should not be treated unless severe. 



1022 



DISEASES OF THE URINARY APPARATUS. 



INFLAMMATION OF THE KIDNEY. BRIGHT'S DISEASE OF THE 

KIDNEY. 

The study of inflammation of the kidney based upon the advances in 
histology and experimental pathology has resulted in such an addition 
to our knowledge that •• Bright* s disease"' and " Bright' s kidney' 7 no 
longer represent a definite picture, but varieties of acute and chronic 
innammation of the kidney are recognized distinct in etiology, anatomical 
changes, and symptoms. The combination of albuminuria and dropsy is 
not essential to all forms of nephritis, and the atrophied kidney of chronic 
Bright' s disease has no necessary relation to the common varieties of 
acute nephritis. The lack of agreement as to what among the affections 
of the kidney shall be called Bright' s disease makes it desirable to ad- 
here as far as possible to an anatomical classification of inflammations 
of the kidney. Such a classification alone leads to distinctions of little 
clinical value, since the alterations of the kidney occurring in nephritis 
affect in various degrees the parenchyma, interstitial tissue, and blood- 
vessels of the kidney. Practically important is the arbitrary distinction 
to be drawn between acute and chronic nephritis, according as the symp- 
toms have existed during a few or during several months. If of less 
than six months' duration, the disease is regarded as acute nephritis ; 
if of more than six months' duration, the nephritis is called chronic. 

ACUTE NEPHRITIS. ACUTE BRIGHT'S DISEASE. 

Synonymes. — Acute catarrhal nephritis ; Acute desquamative nephri- 
tis : Acute j)arenchymatous nephritis ; Acute croupous nephritis j Acute 
diffuse nephritis ; Glomerular nephritis ; Glomerulo-capsular nephritis. 

Etiology. — Infection and toxsemia, the former being the more com- 
mon, are the principal causes of acute nephritis. The infectious varieties 
result from both micro-organisms and their products, and are those in 
which the symptoms characteristic of the infectious disease precede or 
accompany those of the nephritis. This group includes all the infectious 
diseases, although the severity, symptoms, and lesions of the nephritis 
vary within wide limits. The chief importance in etiology is to be 
attached to scarlet fever, diphtheria, infectious sore throat, cholera, 
typhoid fever, small-pox, erysipelas, cerebro- spinal meningitis, typhus 
fever, pernicious malarial fevers, dysentery, tuberculosis, pyaniia, and 
septicaemia. The nephritis in acute articular rheumatism and pneu- 
monia is attributable to the infectious element prevailing in these dis- 
eases. In this series are also to be included many of the cases attributed 
to exposure to cold, also the instances following severe burns and those 
occurring in acute pemphigus. In the second or toxic group of causes 
are to be found cantharides, turpentine, copaiba, cubebs, the mineral 
acids, oxalic acid, carbolic acid, potassium nitrate, potassium chlorate, 
potassium chromate, potassium iodide, phosphorus, arsenic, and corrosive 
sublimate. 



DISEASES OF THE KIDNEYS. 



1023 



Pregnancy a,t times acts as a cause of nephritis, as well as of passive 
congestion of the kidney. 

Morbid Anatomy. — The appearances of the kidney vary according 
to the severity of the affection, its duration, and the localization of the 
changes. In mild cases the alterations may be so slight as to be easily 
overlooked. In the more severe cases the kidneys are increased in size 
and weight, flaccid (in septic cases) or brittle, the capsule easily sepa- 
rated, the surface of the kidney injected, perhaps dotted with punctate 
hemorrhages. On section the cortex is increased in volume, mottled 
from an increased opacity or from a yellow color of the convoluted tubes, 
and in the hemorrhagic cases speckled with blood. The glomeruli and 
blood-vessels are usually injected, but the former may project as translu- 
cent, pale-gray points (glomerular nephritis). The pyramids are of a 
reddish color, and may be streaked with opaque gray lines, due to a 
plugging of the tubular canals with cells escaping from the apices on 
pressure (catarrhal or desquamative nephritis), or to the presence of 
accumulations of bacteria (bacterial nephritis). 

On microscopical examination the tubules are dilated in consequence 
of the swollen, granular, perhaps fatty or necrotic epithelium, and con- 
tain desquamated and disintegrated epithelium, red and white blood- 
corpuscles, and hyaline, granular, and epithelial casts, perhaps blood- 
casts. The glomeruli are enlarged, their nuclei increased ; the capillary 
loops may be plugged with bacteria or hyaline clumps (glomerular ne- 
phritis). In other cases Bowman's capsules are thickened, and the lining 
epithelium is swollen and desquamated (glomerulo-capsular nephritis). 

In addition to various degrees of the above-mentioned alterations, a 
coagulable exudation is often present in the interstitial tissue (croupous 
nephritis), or a cellular infiltration perhaps with red blood- corpuscles 
(diffuse nephritis). 

Symptoms. — In the milder varieties of acute nephritis there may be 
no symptoms calling attention to disease of the kidney, the examination 
of the urine in many of the infectious diseases alone giving evidence 
of the renal affection. The onset of the symptoms varies in accordance 
with the etiology. A chill, followed by moderate elevation of tempera- 
ture, backache, nausea, and vomiting, and, in children, convulsions, may 
precede the dropsy, the most characteristic symptom, or the effusion may 
occur, as in scarlet fever, some time after the symptoms of the infectious 
disease which it complicates have disappeared. 

The dropsy may follow the acute initial symptoms in the course of a 
day or two and rapidly progress, or may gradually appear in the course 
of convalescence from an acute infectious disease. It progresses the more 
rapidly the less the secretion of urine. It is usually first recognized in 
the face, especially as a puffiness of the eyelids, but rapidly involves the 
subcutaneous tissue of the lower extremities and the genitals, perhaps 
extending to the pleural cavities and the lungs. The frequency of dropsy 



1024 



DISEASES OF THE URINARY APPARATUS. 



in certain varieties of nephritis, especially in those dne to scarlet fever, 
pregnancy, malaria, and to the unknown agents included under exposure 
to cold, and the rarity of its occurrence in the other varieties of infec- 
tious nephritis, are explained by Senator by the fact that in the former 
series the glomeruli are conspicuously altered, while in the latter the 
parenchyma is particularly changed. The conspicuous vascular disturb- 
ance in the kidney suggests that the cutaneous vessels also may be diseased, 
hence the dropsy. 

The urine is usually lessened in quantity, although micturition may 
be frequent : such diminution may lie within normal limits, as in the 
nephritis of diphtheria and of many other infectious diseases, or there 
may be actual suppression. Frequently less than a pint is secreted 
during the twenty -four hours. It is high-colored and opaque when scanty, 
but when normal in quantity may show no alteration of color. If blood 
be present, the color will vary from a red or dirty red (smoky) color to 
a dark reddish-brown. The reaction is acid, and the specific gravity 
varies in accordance with the quantity eliminated, ranging from 1020 to 
1035. The percentage of urea in the specimen examined may be high, 
but the total quantity eliminated in the twenty- four hours may be dimin- 
ished to one-sixth the normal amount. Salkowski and Leube consider 
it probable that in glomerular nephritis there may be no considerable 
diminution in the elimination of urea. The quantity of albumin present 
usually varies from one-half to two per cent., although a lesser quantity 
may occur and extensive degeneration be present : further, the urine may 
contain no albumin in the early stage of acute nephritis, and the albumin 
may temporarily disappear, or the albuminuria may persist after the dis- 
appearance of the other symptoms. The sediment is, as a rule, abundant, 
and consists of uric acid crystals and urates, leukocytes, renal epithelium, 
fresh and decolorized red blood- corpuscles, and hyaline, granular, epi- 
thelial, and blood casts. Fatty degeneration of the epithelium is gener- 
ally slight. 

In the further unfavorable progress of acute nephritis, digestive dis- 
turbances, especially nausea and vomiting, persist, and are to be con- 
sidered as the manifestations of a mild uraemia. The tongue is coated, 
and the bowels are usually constipated, although diarrhoea from uraemia 
may occur in the course of the disease. The patient loses flesh and 
strength, and pallor of the skin becomes conspicuous. The red blood- 
corpuscles are diminished, and hemorrhages from the nose and in the 
skin may take place. The ursemic disturbances of the nervous system 
are characterized by headache, restlessness, muscular twitchings or con- 
vulsions, wakefulness, delirium, stupor, or coma. The respiration is but 
little affected, unless ursemic dyspnoea occurs, or hydrothorax, pleurisy, 
or pneumonia takes place as a complication. The heart's action becomes 
intensified, and slight degrees of hypertrophy of the left ventricle may 
rapidly appear, indicated by an outward and downward displacement of 



DISEASES OF THE KIDNEYS. 



1025 



the apex and an accentuation of the aortic second sound, but any con- 
siderable degree of cardiac hypertrophy is rare, especially in scarlatinal 
and diphtherial cases. Pericarditis sometimes develops, and the tension 
of the pulse is increased. At the outset micturition is often frequent 
and sometimes painful, though the total quantity is small, and anuria 
may occur, resulting fatally in the course of a few days. An increased 
flow of urine takes place as convalescence approaches, although the im- 
provement thus indicated may be of temporary character, exacerbations 
and remissions with corresponding modifications in the flow of urine 
being frequent. The skin is not only pale, but often translucent, in the 
early stages, and dry in the later stages, of acute nephritis. Among the 
complications not already mentioned, retinitis, perhaps hemorrhagic, 
sometimes occurs, although less frequently than in chronic nephritis, and 
the inflammation of serous membranes, especially peritonitis, may take 
place without obvious local cause. 

Diagnosis. — The diagnosis of acute nephritis is often easily made by 
the examination of the urine alone, which should be repeatedly under- 
taken in all acute infectious diseases, especially in scarlatina and diph- 
theria, in pregnancy, and after exposure to toxic causes. Acute nephritis 
of less obvious origin is of more likely occurrence during epidemics of 
scarlet fever and diphtheria, and may be first suggested by the presence 
of dropsy, the renal nature of which is quickly disclosed by the urinary 
examination. The absence of any considerable degree of dropsy serves 
to differentiate a parenchymatous nephritis from the glomerular variety 
following scarlet fever, pregnancy, and malaria, and from the u idio- 
pathic" variety of unknown origin. A glomerular nephritis is further 
suggested by the association of a high percentage of albumin with chiefly 
hyaline casts. The occurrence of hematuria and blood-casts is sufficient 
evidence of a hemorrhagic nephritis, while abundant epithelial cells and 
leukocytes in the sediment indicate a catarrhal or a desquamative nature 
of the affection. The association of bacterial casts and typhoidal symp- 
toms is evidence of the septic or pysemic nature of the process. 

Prognosis. — In accordance with the differences in the etiology and 
lesions of acute nephritis, and the variations in its course, the prognosis 
varies within wide limits. Its symptoms may disappear during the con- 
valescence from the acute infectious disease which it complicates, or 
may persist for weeks or months, perhaps for years, in which case the 
acute nephritis is merely the early stage of a chronic nephritis. The 
prognosis, therefore, depends primarily upon the cause. It is usually 
favorable when the nephritis is due to infection, although in scarlatina 
and diphtheria the nephritis may be mild or severe according to the 
nature of the epidemic. Toxic varieties of nephritis also offer a favor- 
able prognosis, provided the quantity of the poison taken has been small. 
The prognosis is uncertain in nephritis of doubtful or unknown origin, 
and in pregnancy. It becomes the more grave the longer the symp- 

65 



1026 



DISEASES OF THE URINARY APPARATUS. 



toms persist, since unfavorable symptoms may suddenly develop, due 
either to ursemia or to acute dilatation of the heart. The mortality is 
high among young children, and the prognosis is more serious in glo- 
merular than in parenchymatous nephritis. An increased flow of urine 
and disappearance of the dropsy are favorable signs, while persistent 
oliguria, a low percentage of urea, and a high percentage of albumin are 
unfavorable signs. Anuria may prove fatal in the course of forty- eight 
hours, but often continues for a week without severe ursemic symptoms, 
and has lasted for eleven days in a patient with gout and renal colic and 
recovery taken place. Periodical examinations of the urine should be 
made for some time after apparent recovery, on account of the frequency 
with which chronic nephritis follows an acute attack. 

Treatment. — The treatment of acute nephritis must vary with the 
cause and severity of the attack, but in all cases there are certain essen- 
tial hygienic methods. The patient should always be put to bed and kept 
in a well- ventilated room at a uniform temperature day and night, and 
should wear an undershirt continuously. The slightest chilling of the 
surface of the body is very dangerous. The diet should be of the simplest 
form, and of such character as to throw the least possible strain upon 
the kidneys. If any solid food be allowed, it should be cracked wheat, 
oatmeal, or other farinaceous article. In most cases an absolute milk 
diet should be insisted upon. Large draughts of water should be taken 
at regular intervals ; hot water is better usually than cold water, and ice- 
water should never be allowed. The total daily amount of liquid taken 
should be five or six quarts, if the stomach will bear it. 

Almost invariably the patient should in the beginning of the attack 
be cupped over the kidney, and in many instances the cupping may be 
repeated with advantage. In sthenic cases following exposure or irri- 
tating poison, wet cups should be used : there should be no fear of 
abstracting blood very freely. In some cases venesection is justifiable. 
When the disease develops during an infectious fever dry cupping is 
often preferable to local blood-letting. During the course of the disease 
continuous counter- irritation over the kidney should be used, care being 
exercised not to employ cantharides, turpentine, or other substances 
which might be absorbed and increase the renal irritation. 

The indications for medicinal treatment are — first, to soothe the kid- 
neys and restore functional activity ; second, to excite excretion through 
other organs and thus lessen the strain upon the kidneys. 

Most of the vegetable diuretics are more or less irritant to the kidneys ; 
the least so are probably digitalis and the double salicylate of theobro- 
mine and sodium, and even these should not be used in the early stages 
of acute Bright' s disease. Potassium citrate (half an ounce to an ounce 
a day) may be given immediately, and may be in part substituted after 
two or three days by potassium bitartrate. When there is alarming 
lessening in the amount of renal secretion, the bitartrate, as the more 



DISEASES OF THE KIDNEYS. 



1027 



active of the two, may be administered in small doses every two hours up 
to an ounce a day. 

To lessen the strain upon the kidney and eliminate excrementitious 
material, purging with salines or with the elaterin pill (see formula 25) 
should he employed with a freedom proportionate to the strength of the 
patient. Once or twice in the twenty-four hours, according to the 
severity of the case, a very profuse perspiration should be produced, 
either by the vapor bath or by pilocarpine administered hypodermi- 
cally or in combination with other diaphoretics. (See formula 7.) 
Very often the vapor or hot- water bath aided by a half dose of pilocar- 
pine acts most happily. When there is fever, with arterial excitement, 
tincture of aconite is a very valuable remedy, which may be given con- 
tinuously in such dose as materially to reduce the force and rate of the 
pulse and to keep the skin continually moist. In many cases a single 
full dose of aconite given once or twice with the pilocarpine acts very 
favorably. 

During the later stages of an acute nephritis the milder vegetable 
diuretics are sometimes of service ; and iron and other remedies useful 
in the chronic disorder may come into play before recovery is insured. 
During convalescence it is essential to keep the patient continuously from 
any chilling, and to avoid kidney strain by restriction to a diet largely 
farinaceous. Very frequently removal to a hot climate is most beneficial. 

In acute suppression of urine the treatment is that of an acute conges- 
tion, — cupping, very active sweating, purging, saline diuretics ; if the 
disease fail to yield, three five-grain doses of calomel may be given, an 
hour apart ; the injection of a quart of aseptic, warm, normal saline 
solution (six-tenths per cent, of salt) into the buttock sometimes acts 
happily ; in desperate cases flannels saturated with the tincture or poul- 
tices of the leaves of digitalis applied over the loins have brought relief, 
but are not free from danger, as E. F. Fannell has reported serious col- 
lapse from a single ounce of the tincture used externally. 

CHRONIC NEPHRITIS. CHRONIC BRIGHT'S DISEASE. 

Lack of agreement exists among medical writers as to the relation 
between the several chronic alterations of the kidney and the processes 
which give rise to them. It is recognized that an atrophied kidney may 
represent a terminal stage, "the third stage," of chronic diffuse nephri- 
tis, and that it may occur independently of the symptoms of this affec- 
tion and probably with a different etiology. It is also recognized that 
an atrophied kidney may result from obstruction to its blood-supply 
dependent on chronic inflammatory changes in the wall of the renal 
arteries, producing stenosis. The anatomist recognizes the large white 
kidney of chronic diffuse nephritis and its contracted state, also the 
genuine atrophied kidney of chronic interstitial nephritis and an atro- 
phied kidney the result of chronic endarteritis. The two latter forms of 



1028 



DISEASES OF THE URINARY APPARATUS. 



atrophied kidney have clinically little in common with the secondary 
atrophied kidney of chronic diffuse nephritis. The term u chronic 
Bright' s disease" or ''chronic nephritis/ 7 therefore, includes a series 
of widely differing anatomical changes which may represent successive 
stages of the same process, or may agree only in a final result, atrophied 
kidney. Clinical convenience is best served by distinguishing between a 
chronic diffuse nephritis and a chronic interstitial nephritis, since the 
symptoms permitting the diagnosis of the former widely differ from those 
attributable to the presence of the latter. 

CHRONIC DIFFUSE NEPHRITIS. CHRONIC PARENCHYMATOUS 

NEPHRITIS. 

Synonymes. — Bright' s disease, second stage ; Large white kidney ; 
Fatty kidney. 

Etiology. — Chronic diffuse nephritis occurs more often in men than 
in women, especially before middle life. It not infrequently represents 
the continuous progress of an acute nephritis, especially the scarlatinal 
and idiopathic (from unknown infection) varieties ; also the nephritis 
of pregnancy. It may follow an acute attack although separated by a 
longer or shorter interval, and the etiology is then to be regarded as 
the same as that of the acute attack, either infectious or toxsemic. In 
other instances the onset is obscure, or the disease may arise as a fatty 
degeneration of the kidney in the course of chronic ansemia, especially 
in phthisis, cancer, gastric ulcer, and pernicious anaemia. The charac- 
teristic appearances of chronic diffuse nephritis at times are found asso- 
ciated with amyloid disease in the kidneys and elsewhere. It is, therefore, 
customary to assign an etiological importance to the general causes of 
amyloid degeneration, as syphilis, chronic suppurative arthritis and 
osteitis, and chronic tuberculosis of the lungs, intestine, and bones. The 
probable significance of these causes is strengthened by the occurrence 
of amyloid degeneration after the focal lesions of nephritis have become 
manifest. 

Morbid Anatomy. — The appearances vary according to the degree 
of the affection of the parenchyma or the interstitial tissue, the duration 
of the process, and, perhaps, the etiology. Especially characteristic is 
the large white kidney, which is increased in size and density, the capsule 
adherent in spots, the surface of a pale-gray color, mottled with white or 
yellow specks seen through a transparent film, and the stellulse Yerheynii 
often conspicuous. A mottled appearance is also seen on section, and is 
due to swelling, opacity, and fatty degeneration of the epithelium of the 
convoluted tubes. The Malpighian corpuscles are indistinct. Punctate 
hemorrhages are at times to be seen both on the surface and on the 
section of the kidney. On microscopical examination the tubules are 
dilated, the epithelium fatty, desquamated, and disintegrated. Leuko- 
cytes and hyaline and fatty casts are present in the canals, and the inter- 



DISEASES OF THE KIDNEYS. 



1029 



stitial tissue is irregularly infiltrated with leukocytes. The glomeruli 
may show changes similar to those seen in acute nephritis. When anae- 
mia is important in the etiology of chronic nephritis, the fatty changes 
predominate over the interstitial alterations. 

The small white kidney represents the atrophic stage of the large 
white kidney, and is due to the shrinkage of the fibrous tissue and the 
absorption or excretion of the fat. The kidney is more nearly of the 
normal size, its density increased, the surface smooth or rough, more 
reddish-gray than white or yellow, although still spotted with the latter 
colors, the cortex diminished in volume. The microscopical examina- 
tion shows a closer approximation of sound and atrophied Malpighian 
corpuscles, also irregular patches of fibrous tissue, in which the tubules 
have disappeared. According to the appearance of the surface a smooth 
atrophied kidney is contrasted with a granular atrophied kidney. Amy- 
loid degeneration may be combined with chronic diffuse nephritis, in 
which case the pallor of the kidney is still more conspicuous. Hyper- 
trophy of the left ventricle of the heart may be present, especially in the 
later stages. The appearances of a kidney in chronic diffuse nephritis 
may be modified by a focal limitation of the alterations involving larger 
or smaller portions of the kidney. Few or many scars throughout the 
kidney, or extensive atrophy of a limited portion, perhaps with compen- 
satory hypertrophy of the remaining part, are to be seen. 

Symptoms. — As in acute nephritis, the characteristic symptoms are 
dropsy and the abnormal condition of the urine ; the former may first 
suggest chronic disease of the kidney, or the latter may be found, as in 
examination for life insurance, before dropsy has made its appearance. 
In those cases in which the onset is gradual and the disease unsuspected, 
symptoms of mild uraemia are likely to be present. Digestive disturb- 
ances are frequent, as loss of ai^petite, nausea, and vomiting at irregular 
times, especially before breakfast, and diarrhoea, headache, and wakeful- 
ness may be associated. The patient loses strength and becomes pale. 

The dropsy is usually first observed in the eyelids, ankles, and feet, 
the puf&ness of the eyelids being seen in the morning, the swelling of the 
ankles and feet in the evening, and extends to the subcutaneous tissue 
throughout the body, and eventually into the serous cavities, lungs, and 
brain. In the atrophic stage with increased flow of urine the dropsy may 
diminish in severity. 

The characteristics of the urine vary somewhat according to the stage 
of the disease. It is usually diminished to two pints or less, but the quan- 
tity may vary considerably from time to time. The color is high or dark 
red, perhaps smoky in appearance, according to the concentration or the 
presence of blood, and is opaque. The reaction is acid, and the specific 
gravity from 1020 upward. Urea is diminished. Albumin is abundant, 
from one to three per cent., the precipitate occupying one-half or the 
whole of the volume of the boiled urine. The percentage is least while 



1030 



DISEASES OF THE URINARY APPARATUS. 



the patient is at rest. The sediment is abundant, and consists of numer- 
ous hyaline, granular, epithelial, and fatty casts of various length and 
breadth, renal epithelium, and leukocytes, either granular or fatty, free 
fat- drops, fat- crystals, and fresh or decolorized red blood- corpuscles, 
sometimes so abundant as to indicate a hemorrhagic nephritis. 

In the atrophic stage the quantity of urine is likely to be either normal 
or increased, the specific gravity 1010 and upward, the percentage of al- 
bumin from one-half to one per cent., the sediment containing abundant 
casts, but with less evidence of fatty degeneration and the addition of 
waxy or colloid casts. With the persistence of the disease the uremic 
disturbances become more severe, and may prove the immediate cause 
of death, although dysentery, delirium, coma, and convulsions are less 
frequent than in acute diffuse and chronic interstitial nephritis. TJraemic 
paralyses and retinitis sometimes occur, especially late in the disease, 
but less frequently than in chronic interstitial nephritis. The heart, par- 
ticularly the left ventricle, becomes somewhat hypertrophied and dilated, 
especially when the disease runs a protracted course. The aortic second 
sound is accentuated, and the tension of the pulse increased. Dyspnoea 
is frequent, may be asthmatic in character, and is due in part to uraemia 
and in part to oedema of the lungs or to hydrothorax. 

The disease usually extends over a period of a few years, during 
which exacerbations and remissions may often occur, sometimes suggest- 
ing successive attacks of acute nephritis. Eecovery is possible when the 
disease is limited to a portion of the kidney, but death usually results 
from progressive emaciation and exhaustion, with oedema of the lungs or 
larynx or concurrent acute inflammation, especially of the lungs or serous 
cavities, or from uraemia. 

Diagnosis. — The diagnosis ultimately depends upon the examination 
of the urine, although persistent anaemia, frequent nausea and occasional 
vomiting without obvious cause, and oedema are sufficiently suggestive 
of a renal affection. The large white kidney of diffuse nephritis may 
be differentiated from that associated with amyloid degeneration by the 
failing etiology of the latter. Evidence of an associated amyloid spleen 
or liver is lacking, while the urine from an amyloid white kidney is 
paler, clearer, and its sediment less abundant, with predominating 
hyaline casts and but few red blood- corpuscles. It is important to dis- 
criminate between the acute exacerbation of a chronic nephritis and an 
attack of acute nephritis. In the former dyspepsia, anaemia, and oedema 
precede the immediate exacerbation, in which the dropsy rapidly in- 
creases 5 the flow of urine is more profuse than in acute nephritis, fatty 
casts are more abundant, and cardiac hypertrophy and albuminuric 
retinitis, if present, confirm the diagnosis of a pre-existing nephritis. 
The atrophic stage of chronic diffuse nephritis is to be diagnosticated 
when, after a prolonged period of dropsy with symptoms of mild uraemia, 
the former lessens, and the quantity of urine is increased, and perhaps 



DISEASES OF THE KIDNEYS. 



1031 



excessive. The color is paler, the specific gravity lower, and the per- 
centage of albumin higher than in the genuine form of atrophied kidney, 
while the sediment is more abundant, containing the variety of casts to 
be found in the urine from large white kidney, but with less fat. 

Prognosis. — The prognosis depends primarily upon the meaning to 
be attached to the term chronic diffuse nephritis. The milder varieties, 
essentially parenchymatous degeneration of the renal epithelium, usually 
terminate favorably, although the subsequent development of a more 
severe nephritis may be attributed to a prolonged period of latency fol- 
lowing the original infection or toxgemia. 

The severe variety of chronic diffuse nephritis demands an unfavor- 
able, though guarded, prognosis. Eecovery undoubtedly occurs when 
the pathological process is limited to a portion of a kidney. Hyper- 
trophy of the rest of the kidney or of the heart then takes place, suffi- 
cient to compensate for the loss of the diseased portion of the kidney. 
The prognosis in recurrent attacks even is not necessarily fatal, since suf- 
ficient unaffected kidney may remain for physiological purposes. The 
prognosis of the case in hand depends upon the duration of the disease, 
the daily quantity of urine, the percentage of urea, and the severity of 
the symptoms, especially upon a sudden increase of the oedema or the 
onset of grave uraemia, and upon the occurrence of complicating dis- 
eases, as erysipelas, pericarditis, pleurisy, or pneumonia. 

Treatment. — The indications for treatment in chronic Bright' s dis- 
ease are — first, to lessen the strain upon the kidney ; second, if possible, 
to check diseased action in the kidneys themselves ; third, to relieve 
symptoms as they arise. 

The work of the kidney may be lessened by diminishing the pro- 
duction of excrementitious material in the body, and by increasing the 
activity of the other emunctories. Moreover, the irritation of the kidney 
under work may be diminished by dilution of the substances which act 
as irritants to the kidney. In order to lessen the amount of excrementi- 
tious material, the nitrogenous food taken should be reduced to the min- 
imum, the chief reliance being upon farinaceous foods. In many, if not 
in all, cases a protracted trial should be made of "skimmed milk" diet, in 
which the patient should take at short intervals during the day such an 
amount of milk as will aggregate from two to four quarts in the twenty- 
four hours. There is no reason for believing that the effects of such diet 
are rendered nugatory by the moderate use of oatmeal, cracked wheat, or 
other thoroughly cooked farinaceous foods, which, moreover, tend to over- 
come the excessive constipation produced by the milk diet. In many 
cases buttermilk, koumiss, or matzoon may be advantageously substituted 
in part or altogether for sweet milk. During the twenty-four hours at 
least three quarts of liquid should be taken ; and if the urine be acid, 
alkalies should be used pro re rata. 

To maintain the action of the skin, the patient should, if possible, 



1032 



DISEASES OF THE URINARY APPARATUS. 



live in a warm, equable climate. If this be not attainable, the greatest 
care should be exercised, by the wearing of heavy woollen underclothing 
day and night, to prevent any chilling of the surface. 

Sweating should be encouraged by the habitual free internal use of 
water ; and at regular intervals, varying from one to four days, a sweat 
should be given by means of pilocarpine, or, as is usually better, by the 
vapor bath. In robust persons the sweat may be daily ; when uraemia 
threatens, twice a day. It is usually better so to arrange that the patient 
shall not go out of his apartments after receiving the vapor bath until 
the next day. 

Although it is doubtful whether any substance can favorably affect 
the nutrition of the chronically inflamed kidney, yet the power which 
has been ascribed by authorities to the strontium salts, especially the 
lactate, more than warrants its trial ; thirty to fifty grains a day may 
be given in divided doses. Ferric chloride (ferri chloridum, from one 
to three grains, in its solid form, or in the form of the tincture or of 
Basham's mixture) is a standard remedy in the second stage of Bright' s 
disease. It is a good ferruginous tonic, is somewhat diuretic, and also 
acts as an astringent. The pure diuretics are chiefly valuable in main- 
taining the action of the kidney or in soothing the irritated kidney. 
Irritant diuretics are usually harmful. 

Although in renal dropsy it is, for obvious reasons, rarely possible to 
get rid of the excess of water by means of diuretics, it is often essential to 
stimulate the kidneys to their utmost. The diuretics which may be used 
for this purpose, enumerated according to their efficacy, are potassium 
bitartrate, sodium and theobromine salicylate, caffeine citrate, and pilo- 
carpine hydrochlorate (one-twentieth of a grain every two hours). Sco- 
parius is irritating to the kidneys, but is less so than squill ; nevertheless 
a pill of calomel, squill, and digitalis, one grain each, is sometimes 
effective in desperate cases after the failure of other remedies. 

When dropsy in renal disease is excessive there is usually a secondary 
cardiac failure, so that caffeine, strophanthus, and digitalis may by in- 
creasing the activity of the circulation be very serviceable. The chief 
reliance in renal dropsy must, however, be put upon sudorifics and pur- 
gatives. If in any case the water in spite of treatment so accumulates 
as to become a source of danger, relief may usually be obtained by punc- 
turing the legs above the ankle, or by making several moon-shaped in- 
cisions just below the internal malleolus. Such a procedure should, 
however, always be delayed as long as possible, as very often the incisions 
refuse to heal. 

The treatment of partial or complete urinary suppression in chronic 
Bright' s disease is essentially the same as that of the same symptoms 
due to acute Bright' s disease. (See page 1027.) Care must, however, 
be exercised in the abstraction of blood. For the treatment of ursemic 
symptoms see page 1038. 



DISEASES OF THE KIDNEYS. 



1033 



CHRONIC FIBROUS NEPHRITIS. CHRONIC INTERSTITIAL 
NEPHRITIS. 

Synonymes. — Bright' s disease, third stage; Gouty kidney; Con- 
tracted kidney ; Cirrhosis of the kidney ; Granular atrophy of the 
kidney. 

Chronic interstitial inflammation of the kidney results in the produc- 
tion of an atrophy of the kidney. A similar result may occur in the late 
stages of chronic diffuse nephritis, in chronic endarteritis of the renal 
arteries, or of the aorta at the origin of these arteries, and in old age, the 
last two conditions being often associated. A distinction is thus drawn 
between the primary or genuine atrophy of the kidney due to a pro- 
gressive inflammation of the interstitial tissue and a secondary atrophy 
of the kidney occurring in the course of chronic diffuse nephritis, local- 
ized chronic endarteritis, or advancing years. The first alone requires 
especial consideration as a well-defined pathological process, although 
the clinical distinction is not always to be sharply drawn between the 
several varieties of atrophied kidney. 

Etiology. — The probable immediate cause of chronic fibrous ne- 
phritis, which is more common after middle life, is long-continued irrita- 
tion of the kidney, the result of gout, syphilis, or malaria, or of alcohol, 
lead, or possibly other poisons. Prolonged obstruction to the outflow of 
urine, chronic pyelitis, and the development of multiple cysts, as in the 
multilocular cystic kidney, are associated with chronic interstitial ne- 
phritis, although in these affections the kidney is usually increased in size. 
It is not unlikely that malassimilation of food resulting from irregularity 
or excess in modes of living, especially in eating, drinking, working, 
and resting, may result in the prolonged elimination through the kidney 
of irritating products of defective digestion or disturbed tissue metamor- 
phosis and thus prove of etiological importance. In this relation the 
frequent association of chronic fibrous nephritis and general arterio- 
sclerosis is significant. Attention has already been called to the possi- 
bility that the alteration of the blood-vessels may be due to the nephritis, 
and to the view of Senator, that in the genuine form of chronic fibrous 
nephritis a persistent toxaemia probably acts simultaneously as an irritant 
both to the blood-vessels and to the kidney. In those instances in which 
a general arterio- sclerosis is combined with chronic fibrous nephritis, it 
seems probable that the etiology is the same for each affection. 

Morbid Anatomy. — The kidneys are diminished in size, in extreme 
instances each weighing perhaps an ounce, and are of increased density. 
The capsule is thickened, and so adherent that, when torn off, portions 
of the kidney are separated with it. The surface is smooth or granular, 
and the granules, both large and small, are composed of relatively un- 
altered tissue, which is of a red or reddish-gray color according to the 
quantity of blood present. A distinction of no essential importance is 



1034 



DISEASES OF THE URINARY APPARATUS. 



sometimes thus drawn between a red and a pale granular kidney. Nu- 
merous minute cysts, and white or yellow specks from lime salts or 
urates, are frequently seen upon the surface and the section of the kid- 
ney, and similarly colored streaks from a like cause may be found on 
section of the pyramids. The cortex is thin and the pyramids short ; the 
glomeruli and tubular regions are indistinct, although the larger blood- 
vessels are unusually conspicuous. On microscopical examination, more 
or less extensive, disseminated patches of fibrous and granulation tissue 
are seen, in which some of the tubules are obliterated while others are 
dilated and varicose and frequently contain globular and cylindrical 
hyaline concretions. The arteries show a tendency to become oblit- 
erated, and the walls both of tubes and of arteries are thickened ; the 
glomeruli, with or without thickened capsules, are transformed into 
homogeneous, glistening, sclerosed bodies, which perhaps are infiltrated 
with lime salts. The combination of chronic fibrous nephritis and the 
deposition of urates is spoken of as a gouty kidney, and is often found 
among persons leading a life of luxury ; while the fibrous kidney associ- 
ated with lime salts has been regarded as evidence of a poor man's gout. 

The general nutrition of persons with chronic fibrous nephritis may 
be but little affected : indeed, the atrophied kidney is not infrequently 
embedded in abundant fat-tissue. A most important associated lesion is 
concentric idiopathic hypertrophy, sometimes extreme, of the heart, 
either of the left ventricle alone or of both ventricles. The degree of 
the hypertrophy depends upon the duration of the disease and the 
general nutrition of the patient ; the cause has been mentioned in the 
consideration of the cardio-vascular changes in nephritis. The hyper- 
trophied heart may subsequently undergo fatty degeneration and the ven- 
tricular cavity become dilated. Retinal hemorrhages and albuminuric 
retinitis are more frequently found than in chronic diffuse nephritis. 
Chronic endaortitis (atheromatous degeneration of the aorta) and scle- 
rosis of the smaller arteries in various organs of the body may be asso- 
ciated with a chronic fibrous nephritis, also pulmonary emphysema, 
cerebral hemorrhage or softening of the brain, and fibrinous inflamma- 
tion of the serous membranes of the body. 

Symptoms. — The symptoms of chronic fibrous nephritis may be so 
slight, ill defined, or remotely related to the kidney that the condition 
of this organ is unsuspected until an examination for life insurance dis- 
closes an abnormal urine, or a troublesome heart-beat or a feebleness of 
eyesight leads to a physical examination of the heart or retina, revealing 
lesions at once suggesting a chronic nephritis. The patient may consider 
his kidneys exceptionally sound, since urine is excreted with unusual 
freedom. As a rule, the earliest symptoms are those due to a mild uraemia. 
The patient complains of dyspepsia. He suffers from slight nausea, per- 
haps from vomiting at irregular times and independently of the ingestion 
of food. For a long time the digestive power of the stomach is unaffected 



DISEASES OF THE KIDNEYS. 



1035 



and the general nutrition of the patient is excellent. During this period 
there is occasional vertigo, perhaps headache, usually mild, although 
sometimes persistent, also neuralgia, either occipital or following the dis- 
tribution of the facial nerve. Itching of the skin may be complained 
of, and persistent eczema is not infrequent. The patient becomes short- 
breathed on exertion, or has asthmatic attacks, and recognizes a power- 
ful beating of the heart. Thirst occurs combined with frequent mic- 
turition, especially noticed at night, and polyuria, symptoms which 
lead the patient to suspect diabetes. In virtue of one or more of these 
disturbances, an examination of the urine is made, and reveals the fol- 
lowing characteristics. The quantity is excessive, three to four quarts 
(3000 to 4000 cubic centimetres). The color is pale and the urine 
transparent, the reaction acid, the specific gravity from 1005 to 1010, 
being higher in the urine passed during the day than in that passed 
after rest. The urea is somewhat diminished, while albumin is present 
from a trace to one-fourth per cent. At times it may be temporarily 
absent, or not recognized for weeks or months, or it may be present 
only during the day. Indeed, we have seen fatal uraemia from con- 
tracted kidney with urine that was of normal specific gravity and 
free from albumin. The percentage of albumin is usually less in the 
urine passed during the night than in that voided by day. The sedi- 
ment is slight and contains but few, usually narrow, hyaline casts, and 
repeated examinations may be necessary before casts are seen. Granu- 
lar casts are exceptionally found, and fat-drops are infrequent. Renal 
epithelium, leukocytes, and red blood- corpuscles are rare. 

In the further progress of the disease the dyspeptic symptoms, par- 
ticularly the nausea and vomiting, persist, and may be associated with 
obstinate diarrhoea, and the patient often, though not necessarily, loses 
flesh and strength. Anxiety and wakefulness are frequent. Muscular 
twitchings, at times convulsions, may take place, also disturbance of 
vision, and, especially towards the end of life, stupor or coma. The 
more severe uraeinic disturbances may last but a short time or may 
recur with intervals of comparative health. 

The recognition of the cardiac hypertrophy without valvular disease 
is of the greatest importance in calling attention to the condition of the 
kidney. It is manifested not only by palpitation and displacement of the 
apex downward and outward, but also by the increased area of cardiac 
dulness, especially to the left, and by the accentuation of the aortic second 
sound. Increased arterial tension is indicated by the resistant, radial 
pulse, the cord-like character of the artery suggesting a sclerosis of its 
wall. Throbbing of the temporal arteries, headache, and perhaps hemor- 
rhages, nasal, cutaneous, or cerebral, are additional evidence, in part at 
least, of increased arterial tension. In the later stages of the disease, 
when the nutrition of the heart becomes impaired and dilatation is added 
to hypertrophy, as indicated by an extension of dulness to the right and 



1036 



DISEASES OF THE URINARY APPARATUS. 



perhaps a systolic souffle at the apex, the pulse becomes weaker, more 
frequent, and irregular, the dyspnoea more persistent, and dropsy may 
occur, the absence of which throughout the greater part of the disease 
strongly contrasts this variety of chronic nephritis with that due to diffuse 
inflammation of the kidney. 

The early disturbances of respiration are probably the result of a mild 
uraemia, but in the further advance of the disease the dyspnoea, though 
often paroxysmal, is aggravated by mental or physical strain, and may 
assume a Cheyne-Stokes character, or be combined with oedema of the 
lungs or with bronchial catarrh. Such modifications in the character of 
the respiration suggest that the late dyspnoea is due rather to the failing 
competency of the heart than to uraemia alone. 

The disturbances of vision range between an enfeebled eyesight and 
complete blindness. The latter may occur as a manifestation of uraemia 
in the absence of observable retinal lesions. As a cause of the obscured 
vision characteristic retinal changes are often found, which are included 
under the term albuminuric retinitis. Such are multiple hemorrhages 
and opaque glistening patches due to a fatty degeneration and sclerosis 
of the retina. More rare are other causes of loss of vision, as separation 
of the retina, embolism of the central artery, hemorrhage into the vitre- 
ous, or inflammation of the choroid. 

Of other affections which may arise, acute inflammation of serous 
membranes is frequent, as are also acute pneumonia and dysentery, which 
not infrequently represent the immediate cause of death in a chronic dis- 
ease whose date of origin is uncertain, and whose duration from the onset 
of symptoms attributable to renal disease may extend over a period of 
ten or more years. 

Diagnosis. — Repeated examinations of the urine are usually neces- 
sary for making the diagnosis, although a suspicion of contracted kidney 
should always arise when palpitation, dyspepsia without obvious cause, 
wakefulness, frequent micturition, or unusual disturbance of vision is com- 
plained of. Stewart has emphasized the diagnostic importance of an ap- 
preciation of the symptoms of chronic fibrous nephritis, since there may 
be repeated failures to detect albumin, and casts may be only occasionally 
found. A pulse of high tension even with a cord-like radial artery is no 
necessary evidence of present or impending fibrous nephritis, since both 
may occur without any involvement of the kidney, and a failing cardiac 
compensation in the last stage of fibrous nephritis simulates that present 
in chronic valvular endocarditis. Repeated examinations of the urine 
are especially necessary in the former case, and, although as the heart 
fails the percentage of albumin may increase and the specific gravity 
rise, the latter is still low in proportion to the quantity of urine elimi- 
nated, nearer 1010 than 1020, whereas in chronic passive congestion of 
the kidney the specific gravity is always high. The characteristics of 
the urine in the atrophic stage of a chronic diffuse nephritis are sufficient 



DISEASES OF THE KIDNEYS. 



1037 



to exclude this variety of fibrous kidney, although in senile atrophy and 
in atrophy due to chronic endaortitis the composition of the urine may 
resemble that of genuine chronic fibrous nephritis ; but failing health in 
such cases is not associated with the progressive development of the 
symptoms recorded during a period of years. It is probable that the 
senile and arterio-sclerotic varieties of atrophied kidney are those in 
which albuminuria and casts may occur at times during a period of years 
in individuals in seeming health. 

Prognosis. — Although genuine chronic fibrous nephritis is a progres- 
sive affection, eventually proving fatal, a long period of years may elapse 
during which the individual leads an active, useful, and enjoyable life. 
Death may then occur unexpectedly from sudden cerebral hemorrhage 
or grave ursemia, or more gradually from an acute inflammation, as of the 
serous membranes, lungs, or intestines. In other cases death is of more 
gradual onset in consequence of the failure of cardiac compensation, 
which is often indicated by a diminution in the quantity of urine before 
oedema of the lungs or of the larynx or severe urseniic symptoms, such 
as Cheyne-Stokes breathing, convulsions, sleeplessness, sopor, or coma, 
become manifest. 

Treatment. — It is manifestly impossible to restore the tissue of the 
kidney which has undergone contraction. In many cases the structural 
alteration is due to recurrent subacute attacks, caused by irritant poisons 
which are usually the products of malassimilation within the body. Ee- 
current attacks of oxaluria, or more frequently of lithuria, may each be 
accompanied by urine of low specific gravity containing a little albumin 
and hyaline tube- casts, although between the paroxysms the urine is 
entirely normal. These temporary attacks, which are almost invariably 
overlooked until the kidneys are ruined, may be looked upon as repre- 
senting the early stages of gouty or other form of contracted kidney. It 
is therefore of the greatest importance that the urine of middle-aged 
persons be repeatedly examined during periods of uric acid elimination, 
after heavy eating or drinking, or whenever sediment is noticed. The 
detection of such renal attacks should lead to the institution of strenuous 
measures to prevent the formation in the body of irritant substances, and 
to aid in the elimination of these substances when formed. 

At the basis of many cases of contracted kidney is the habit of over- 
eating of nitrogenous foods and of under-exercising. In any case the 
diet should be made as far as may be farinaceous ; systematic exercise 
should be insisted upon, and every care be taken to maintain the activity 
of the skin by warm clothing and frequent bathing. Alike to the over- 
worked men and to the indolent, over-luxurious women who make up 
a large proportion of the richer population in our large cities, the for- 
mation of the Turkish bath habit in early middle life is important as a 
prophylaxis against renal contraction. 

The management of a case of contracted kidney is in its general prin- 



1038 



DISEASES OF THE URINARY APPARATUS. 



ciples similar to that of other forms of chronic Bright' s disease. (See 
page 1031.) Usually, however, there is no hope of affecting the kidney 
for good, and the utmost that can be done is to regulate the diet so as to 
lessen kidney strain, to stimulate the skin and intestinal tract to elimi- 
nate as much as they can, to give iron to aid in blood reconstruction, and 
to meet uraernic symptoms as they arise. 

In the treatment of uraemia, the chief effort must be to bring about 
elimination of the poisonous materials from the blood. The diuretics 
used should be as far as possible unirritating. By means of pilocarpine 
and the vapor baths very free sweating may be induced. As elaterium is 
accredited with the especial power of causing excretion of urea from the 
intestines, it is generally to be preferred among the purgatives. (See 
formula 25. ) In uremic congestion or oedema of the lungs, free dry or 
sometimes wet cupping, with administration of oil of eucalyptus and 
other stimulating expectorants, is in order. In ursemic convulsions, 
venesection, anaesthetics, chloral, and bromides may be used, with due 
adaptation to the individual case. In ursemic vomiting, cocaine, car- 
bolic acid, and other anti-emetics may be given, but usually fail to ac- 
complish much : whilst the food should be of the lightest kind, and in 
extreme cases should be given for a time solely by the rectum. 

AMYLOID DEGENERATION. 

Amyloid degeneration or infiltration of the kidney may occur as a 
complication of chronic diffuse and chronic fibrous nephritis, and at times 
in an otherwise normal kidney. In the latter case it is of no practical 
importance, but in the former it produces modifications worthy of note 
in the course of chronic Bright' s disease. 

Etiology. — Amyloid degeneration in the kidney, as elsewhere in 
the body, is the result of chronic tuberculosis of the lungs, intestines, 
and bones in particular, and then especially when associated with ulcer- 
ation or cavity formation. It also occurs in the sequence of chronic 
suppuration, particularly of the bones, and in empyema and syphilis ; 
lead poisoning, gout, and malaria have also been considered as of 
etiological importance. It is usually associated with amyloid disease of 
the spleen, liver, and intestine, but it may be limited to the kidneys, 
in which case the etiology is obscure. The suppurative conditions are 
generally considered as sometimes concerned in the production of chronic 
diffuse nephritis, while lead poisoning, gout, and malaria are mentioned 
in the etiology of chronic fibrous nephritis. It is therefore possible that 
chronic nephritis and amyloid degeneration of the kidney may be in- 
dependent results of the same cause, as it is to be recognized that in 
consequence of these causes nephritis without amyloid degeneration and 
amyloid degeneration without nephritis may occur. It is also possible, 
although less probable, that existing amyloid degeneration of the kidney 
may occasion the nephritis. 



DISEASES OF THE KIDNEYS. 



1039 



Morbid Anatomy. — The amyloid degeneration of an otherwise 
normal kidney may produce no characteristic gross changes, with the 
exception of pallor and translncency of the glomeruli, hut the presence 
of amyloid disease in chronic diffuse nephritis is always to be suspected 
when a large white kidney is found, and the paler the kidney the more 
probable is the presence of the amyloid material. The amyloid degenera- 
tion may occur in atrophied kidneys of whatever origin, though it is per- 
haps most frequently found in the secondary atrophy of chronic diffuse 
nephritis. Pallor of the kidney and translucency of the glomeruli, again, 
may be the only appearances suggestive of the presence of the amyloid 
substance, which usually manifests itself first as a homogeneous trans- 
lucent thickening of the walls of the glomerular capillaries and of the 
afferent arteries. It may also be present in the blood-vessels and in 
the basement membrane of the tubules in the pyramids. Its presence 
is to be recognized by the application of the compound solution of iodine, 
which produces a mahogany -brown color. The effect of amyloid degen- 
eration of the blood-vessels is to produce a diminution of their calibre, 
and this may act as one factor in the causation of the fatty degeneration 
of the epithelium which is present in the large white amyloid kidney. 

Symptoms. — The symptoms connected with amyloid degeneration of 
the kidney vary in character according to the associated lesion of the 
kidney. They may, therefore, simulate either those of a chronic diffuse 
or of a chronic fibrous nephritis, or there may be no suggestive symptoms 
that the amyloid degeneration is present if the kidney is otherwise nor- 
mal. Albuminuria is constant and dropsy frequent. Polyuria, ursemic 
symptoms, and symptoms referable to hypertrophied heart or to retinitis 
are rare. The patient is pale and weak, and is likely to suffer from diar- 
rhoea in consequence of associated amyloid enteritis, and to present evi- 
dence of enlargement of the liver and spleen from amyloid disease of these 
organs. The quantity of urine is not especially increased, and, when the 
kidney alone is affected, may be diminished to about one thousand cubic 
centimetres in the twenty-four hours. It is acid, clear, of a pale-yellow 
color, its specific gravity 1010 to 1015. Albumin is usually copious, in 
the vicinity of two per cent. Senator states that globulin is abundant. 
There is but little sediment, and this contains comparatively few hya- 
line, granular, fatty, and waxy casts, leukocytes, and red blood-corpus- 
cles. The combination of amyloid degeneration and diffuse nephritis 
may be associated with a diminished quantity of urine and an abundant 
sediment of casts and leukocytes, while the quantity of urine may be 
profuse, with a high percentage of albumin if the amyloid degeneration 
has affected a preceding granular atrophy of the kidney with hypertro- 
phied heart. If amyloid degeneration is present in an atrophied kidney 
without hypertrophied heart, the quantity of urine and the sediment 
may be slight and the quantity of albumin considerable. Cases occur in 
which in the absence of hypertrophy of the heart and a diminished quan- 



1040 



DISEASES OF THE URINARY APPARATUS. 



tity of urine albumin is absent, or is present merely in traces, and only a 
rare narrow hyaline cast is found. 

Diagnosis. — The presence of amyloid degeneration of the kidney is 
to be inferred when an efficient cause for general amyloid disease exists 
and there is evidence of amyloid disease elsewhere, especially enlarge- 
ment of the liver and spleen and chronic diarrhoea. It is rendered prob- 
able when the urine contains abundant albumin and but little sediment 
and there is no evidence of hypertrophy of the heart. 

Prognosis. — Since amyloid degeneration usually represents a late 
stage of the diseases in which it occurs, and of which the prognosis is 
grave, the outlook for the patient is serious. It is possible that the 
progress of amyloid degeneration may cease with the arrest of the dis- 
ease, and it is known that amyloid material may remain in the body 
indefinitely without being productive of disturbance. Its presence in the 
kidneys, however, is usually connected with incurable extensive disease 
in these organs and elsewhere. 

Treatment. — Amyloid degeneration of the kidney cannot be met by 
any specific treatment, and often does not modify the therapeutics of the 
primary disease which causes it. Gallic acid is sometimes useful in con- 
trolling an excessive loss of albumin. 

SUPPURATIVE NEPHRITIS. ABSCESS OF THE KIDNEY. 

Suppurative inflammation of the kidney results in the presence of 
abscesses, which may be few or many, sharply localized or disseminated 
throughout the kidneys. Such abscesses are to be regarded as depend- 
ent upon the entrance into the kidney of pyogenic bacteria, which are 
admitted directly, as in traumatism, or indirectly through the circula- 
tion or by means of the urinary tract. When the bacteria are brought 
through the circulation, the abscess is sometimes called metastatic 5 
while the term surgical Tcidney is often given to that variety of suppurative 
nephritis which results from the extension of an inflammation upward 
from a lower point in the urinary tract, since such a progress has been 
the frequent immediate result of a surgical operation on the urethra 
or the bladder. 

The metastatic abscesses of the kidney which result from the transfer 
of bacteria by means of the blood- current are usually of embolic origin, 
infectious or septic emboli containing bacteria being transferred from the 
heart, as in infectious endocarditis, or from an infectious thrombus in the 
lungs, or in a body vein through an open foramen ovale. It is also pos- 
sible that a suppurative nephritis may arise from the combination of 
bacteria in the renal circulation and a local disturbance in the kidney 
favoring their growth. Abscesses of the kidney are therefore grouped 
as the traumatic, resulting from injuries whether by accident or by 
design ; the embolic, occurring in those diseases in which a malignant 
endocarditis exists as the local expression of a general infection, whether 



DISEASES OF THE KIDNEYS. 



1041 



regarded as pysemia, septicaemia, puerperal fever, rheumatism, osteo- 
myelitis, diphtheria, typhoid fever, dysentery, tuberculosis, or actino- 
mycosis j finally, the pyelonephritic, in which the inflammatory process 
is extended from the urethra, bladder, ureter, and renal pelvis, whether 
induced by surgical operations, including catheterization, by gonorrhoea, 
by renal calculus, or by unknown causes. 

Morbid Anatomy. — One or many abscesses are present in the kid- 
ney, varying in size from that of a pin-head to one involving the space 
between the capsule and the pelvis of the kidney. The abscesses are 
either discrete or confluent, and the wall smooth or shreddy. The sup- 
puration may extend to the paranephric fat- tissue, and result in a para- 
nephric abscess, which, as well as the renal abscess, may communicate 
with the pelvis of the kidney or with the digestive tract, especially the 
colon, duodenum, or stomach. A depressed scar or a calcified nodule 
is sometimes found in evidence of the previous presence of an abscess 
of the kidney. 

Symptoms. — The presence of the abscesses is usually indicated by ir- 
regularly recurring chills, with corresponding elevations of temperature, 
and a continued intervening fever, with less extreme elevation of tem- 
perature, and with the disturbances of digestion, circulation, and res- 
piration and the nervous symptoms characteristic of fever. There is 
but little pain, except when the kidney is injured or the abscess extends 
beyond the kidney, especially when the peritoneum is approached. 
Although albuminuria is present and is sometimes abundant, the per- 
centage may be no higher than exists in febrile conditions in which there 
is no local disease of the kidney. Hyaline and epithelial casts, renal 
epithelium, and leukocytes may be present, but red blood- corpuscles are 
almost always absent. If the abscess breaks into the renal pelvis, pus 
in considerable quantity suddenly appears in the urine. 

Diagnosis. — A traumatic suppurative nephritis is apparent when the 
symptoms mentioned are the immediate result of an injury. The embolic 
variety of suppurative nephritis is to be inferred from the presence of 
signs of a malignant endocarditis in a patient in whom increased albu- 
minuria, and especially the sudden appearance of pyuria and perhaps 
pain in the region of the kidney, indicate a localized inflammation of this 
organ. Especial consideration will be given to that variety of suppura- 
tive nephritis which extends from below upward, pyelonephritis, and to 
the extension of the abscess from the kidney to the paranephric fat- tissue, 
paranephric abscess or suppurative paranephritis. 

Prognosis. — The pus from an abscess of the kidney may become 
absorbed or discharged, the prognosis in the former case being mild, in 
the latter serious, perhaps grave, according as the pus escapes into the 
urinary or into the digestive tract. The pus may be discharged into a 
neighboring hollow organ, with the production of a fistula, which, if in 
communication with the digestive tract, is likely to end fatally. 

G6 



1042 



DISEASES OF THE URINARY APPARATUS. 



CHAPTEE II. 

CYSTS AND TUMORS OF THE KIDNEY AND DISEASES OF THE RENAL 
PELVIS AND THE BLADDER. 

RENAL CYSTS. 

Cysts are of frequent occurrence in the kidneys, and may be found in 
an otherwise normal kidney or in one which is diseased. In the former 
there may be one or several, usually not larger than an apricot, although 
sometimes of sufficient size to produce an abdominal tumor which may 
cause mechanical disturbances. 

The cysts to be found in diseased kidneys are multiple, sometimes 
innumerable, and in greater or less number are a constant accompaniment 
of chronic fibrous nephritis, in which affection they are of secondary 
importance. They are sometimes in such numbers and of such size as to 
produce extreme enlargement of the kidney, forming abdominal tumors, 
the multilocular cystic kidney, and being eventually accompanied by 
symptoms of grave renal disease. The cysts in an otherwise normal kid- 
ney or in one of chronic fibrous nephritis are considered to arise from a 
dilatation of the tubules or of Bowman's capsules by obstruction to the 
escape of urine. The larger result from the fusion of the smaller cysts, 
and contain an albuminous fluid, either serous or gelatinous, in which 
crystals of uric acid, calcic oxalate, and cholesterin, also fat or blood, 
may be present. 

MULTILOCULAR CYSTIC KIDNEY. CYSTIC DROPSY OF THE 

KIDNEY. 

Definition. — Enlargement of the kidney due to the formation of 
innumerable cysts in one or usually in both kidneys, and producing 
symptoms resembling those of atrophy of the kidney. 

Etiology. — The multilocular cystic kidney is a congenital affection, 
and its method of origin is variously explained. A foetal nephritis, con- 
genital closure of the papillse, or an irregular development of the Wolffian 
bodies has been offered in explanation. This abnormity has repeatedly 
occurred in children of the same mother, and has been associated with 
other deformities, as hydrocephalus, cleft palate, club-foot, and cysts of 
the liver. 

Morbid Anatomy. — Both kidneys are usually symmetrically en- 
larged, forming tumors in the adult as large as an infant's head and in 
the new-born child of the size of the fist. The enlarged kidney is lobu- 
lated from the presence of innumerable cysts, from those of microscopic 
size up to others as large as plums, separated from each other by an inter- 



CYSTS AND TUMORS OF THE KIDNEY. 



1043 



vening fibrous structure in which the renal tubules and glomeruli are 
here and there to be recognized. The contents are a thin watery fluid in 
which urinary salts and albumin are often found, and in which hemor- 
rhages are not infrequent. Blood- pigment, fat, and cholesterin may also 
be present. 

Symptoms. — The multilocular cystic kidney may exist for years with- 
out the production of symptoms, since they are not infrequently found in 
persons dying of acute disease. At the same time such a degree of dis- 
tention of the abdomen may occur in the foetus that childbirth is inter- 
fered with, or the descent of the diaphragm is so prevented as to cause 
the death of the infant from asphyxia. The longer the individual lives 
the larger the diseased kidney, since the size and perhaps the number of 
the cysts increase with the growth of the possessor, while the secreting 
structure of the kidney lessens. In the adult, therefore, symptoms are 
likely to become manifest, but the tumors are rarely of such size as to 
produce mechanical disturbances, although the diseased kidney has been 
removed by the surgeon ignorant of its nature. The disturbances which 
arise are rather those of digestion, circulation, and nutrition, with an 
excessive flow of pale urine of low specific gravity, and with a trace of 
albumin due to the associated chronic fibrous nephritis, which increases 
in degree with the age of the individual. As a rule, these symptoms, 
like those of the granular kidney, become conspicuous after middle life. 

Prognosis. — The prognosis is that of fibrous nephritis, necessarily 
grave, although years may elapse after the discovery of the tumors and 
the recognition of their cause before death occurs. Early death may be 
expected if appreciable enlargement of the kidneys from the presence of 
cysts is found in the new-born child. 

Treatment. — The medical and hygienic treatment of cystic kidney is 
that of chronic fibrous nephritis. As both kidneys are invariably more 
or less diseased, surgical excision is rarely, if ever, justifiable. 

tumors of the kidney. 

Of the benignant variety of tumors of the kidney, fibroma, lipoma, 
myxoma, angioma, and adenoma may be mentioned, although they are 
of insufficient size and number to be of any practical importance. Gra- 
witz has shown that the adenoma of the kidney, the gross appearance of 
which often resembles the lipoma, may proceed from displaced portions 
of the suprarenal capsule. The malignant tumors of the kidney are 
sarcoma and cancer. The former sometimes, especially in children, 
contain muscular fibres, constituting myosarcoma. 

Cancer and sarcoma of the kidney occur both as primary and as 
secondary tumors, present similar gross appearances, produce like symp- 
toms, and are to be distinguished, sometimes with difficulty, only by a 
microscopical examination. 

Etiology. — Primary malignant disease of the kidney occurs oftener 



1044 



DISEASES OE THE URINARY APPARATUS. 



in males than in females, rather in early or late adult life than during 
the intervening period, and occasionally is to be found at birth. Sec- 
ondary cancer owes its origin to disease in the vicinity, and particularly 
to primary malignant disease of the testis. 

Morbid Anatomy. — One or both kidneys may be affected, and the 
right kidney is more often diseased than the left in secondary cancer of 
the kidney. Both the primary and secondary varieties occur as a diffuse 
infiltration or as nodules, the latter being more frequently the case in 
secondary cancer. As a rule, the affected kidney is increased in size, 
sometimes enormously, forming a tumor as large as a man's head, weigh- 
ing twenty pounds, and producing an appreciable distention of the abdo- 
men and displacement of the abdominal viscera. The surface is usually 
lobulated. On section the fibrous capsule of the kidney niay overlie the 
tumor, or may have been perforated by the latter, or the neoplasm may be 
everywhere separated from the kidney by the capsule, in which case the 
adrenal origin of the growth is to be suspected. The shape of the kidney 
is usually maintained. The consistency of the mass varies throughout 
or in different portions, from the scirrhous to the soft medullary or en- 
cephaloid mass. The infiltrating cancer of the kidney even when exten- 
sive often preserves the distinction between the cortex and the pyramids. 
The color of the tumor varies from gray or grayish white through yellow 
to red or black, as fatty degeneration, necrosis, hemorrhage, and pigment 
formation exist often in the same tumor. The neoplasm may grow into 
the renal vein, thence into the inferior vena cava, and frequently projects 
into the pelvis of the kidney, which may be dilated and completely filled. 

Symptoms. — Malignant disease of the kidney may progress without 
localizing symptoms. Usually progressive loss of flesh and strength and 
anaemia are present. Among the earliest symptoms suggesting that the 
region of the kidneys is concerned are pains, either fixed or shooting 
outward and downward, and attributable to an extension of the growth 
to the lower dorsal and lumbar nerves. Most important as an early 
symptom is hematuria, which may be constant or intermittent, slight 
or so considerable as even to prove rapidly fatal. With extensive 
hemorrhage and perhaps excessive attacks of renal colic, worm-like 
clots of blood may be voided with the urine. Cells or fragments of the 
tumor may also escape with the urine. The cells, unless containing 
glycogen, are of little value in diagnosis, owing to the variety of shapes 
assumed by the epithelium of the urinary tract. Attention has already 
been called to the diagnostic importance of the glycogenic generation 
in such cells. If fragments of the tumor are voided, a microscopical 
examination may reveal their nature. Most important in diagnosis is 
the recognition of the tumor, which is usually easily accomplished by 
bimanual palpation. Its renal nature is to be suspected from the shape 
and the seat in the lumbar region, the position behind the colon deter- 
mined by inflation of the latter, and the usual lack of mobility. It is 



DISEASES OF THE RENAL PELVIS. 



1045 



overlaid and also separated from the liver and spleen by the resonant 
intestine when not pushed aside, while the spleen, if enlarged, may be 
felt as a moving body in front of the disea-^d kidney. If the surface is 
lobulated and the consistency soft, the sensation of fluid may be suggested, 
and the aspirator may be used to determine the liquid or solid nature of 
the mass. Urea or fragments of cancer may be aspirated. 

Diagnosis. — Persistent renal hematuria, suggested by the dark-red 
color of the urine, the absence of clots, and the presence of albumin 
throughout the fluid, and of fragmented red blood-corpuscles, with or 
without pain, and with cachexia, points to cancer of the kidney even in 
the absence of enlargement. Progressive cachexia with persistent violent 
pain in the region of the kidney which cannot otherwise be accounted for 
warrants the gravest suspicion of malignant disease, even if there be no 
discoverable tumor and no abnormality of the urine. Tumors of the 
kidney are usually readily distinguished from an enlarged spleen by the 
mobility and the characteristic edge of the latter. Tumors of the liver 
and a distended gall-bladder are also easily movable, and are not overlaid 
by the distended colon. Pelvic tumors proceed from below, and are not 
covered by intestine. The determination of the solid nature of the renal 
tumor may require the use of the aspirator and the chemical and micro- 
scopical examination of the aspirated contents. 

Prognosis. — When but one kidney is the seat of the tumor the prog- 
nosis is more favorable than if both kidneys are affected, since extirpation 
of the diseased kidney when sarcomatous has been followed by relief 
of the symptoms and prolongation of life. Malignant disease of the 
kidney under medical treatment generally proves fatal in the course of a 
year or two after its recognition. Death occurs from prolonged cachexia, 
or from the occurrence of gangrene of the tumor, which often results 
from the establishment of fistulse between the growth and the intestine 
or the surface of the body, or the fatal issue may take place rapidly from 
hemorrhage, from rupture of vessels near the surface of the tumor, 
either into the urinary tract or into the peritoneal cavity. 

Treatment. —The medical treatment of malignant tumor of the 
kidney practically amounts to the administration of narcotics for the 
relief of pain. Only in very rare cases can the diagnosis be reached 
sufficiently early in true cancer to justify excision. According to Abbe, 
even in sarcoma of the kidney it is very seldom that the case survives 
beyond three years. The immediate mortality from nephrectomy for 
malignant disease of the kidney has been about fifty per cent. (Barth. ) 

PYELITIS. PYELONEPHRITIS. 
Inflammation of the pelvis of the kidney, and inflammation of the 
kidney as a result of the former, demand conjoint consideration from 
their unity of origin and their frequent concurrence. A pyelonephritis 
is due to a pyelitis, although the latter may occur without the former. 



1046 



DISEASES OF THE URINARY APPARATUS. 



Etiology. — Inflammation of the mncons membrane of the pelvis of 
the kidney, pyelitis, is the result of the presence of an irritant, usually 
bacterial, conveyed from below upward, from the bladder along the 
ureter, or from above downward, as may occur in infectious diseases, 
e.g., scarlet fever, diphtheria, small-pox, typhoid fever, pneumonia, and 
tuberculosis, or in the elimination of such poisons as cantharides, turpen- 
tine, copaiba, and cubebs. In this series belong the instances of pyelitis 
occurring in diabetes attributed to the elimination of glucose. The 
irritant may be transferred from adjacent parts, as in the case of the 
rupture of a neighboring abscess into the renal pelvis. Pyelitis may be 
induced or aggravated by the presence in the pelvis of the kidney of a 
foreign body, as a calculus, parasite, or blood-clot, or by the presence of a 
tumor growing and degenerating in the pelvis of the kidney. Finally 
are to be recognized cases of pyelitis called idiopathic or spontaneous, 
which are attributed to exposure to cold. 

The bacterial varieties of pyelitis, especially when due to an extension 
of inflammation from the bladder, are those productive of pyelonephritis, 
and have been most frequently occasioned by the use of unclean catheters 
and other instruments, and by the failure to avoid sepsis in operations on 
the bladder and urethra. The occasional occurrence of pyelitis after par- 
turition is also to be thus explained. Both pyelitis and pyelonephritis 
are more frequent in men than in women, and in adult life than in youth. 

Morbid Anatomy. — The inflamed mucous membrane presents the 
characteristics of a catarrhal, suppurative, or diphtheritic pyelitis, the 
first indicated by swelling and injection of the mucous membrane, perhaps 
with the addition of punctate hemorrhages and of opaque residual urine 
in the pelvis of the kidney. In the suppurative variety the mucous mem- 
brane is thickened, and the injected blood-vessels are less conspicuous 
than in the catarrhal state, but pus is present in greater or less quantity 
in the pelvis of the kidney, and the mucous membrane may be ulcerated. 
In diphtheritic pyelitis superficial necroses are present, in which urinary 
salts are frequently precipitated, and the apices of the pyramids may 
also be necrotic or destroyed. When hemorrhages occur in the inflamed 
mucous membranes, the term hemorrhagic pyelitis is applied. If the 
inflammation has extended from below upward, similar appearances may 
be found in the bladder and ureters, although the latter often show evi- 
dences of a catarrhal inflammation while an ulcerative or a diphtheritic 
inflammation is present in both the bladder and the pelvis of the kidney. 
The alterations may affect one or both kidneys. 

Pyelonephritis is characterized by the presence of opaque gray or 
yellowish-gray, more or less beaded streaks continued along the pyra- 
mids from their apices into the cortex of the kidney. Such streaks and 
spots have an injected border, and, as they enlarge, tend to become 
confluent and softened in the centre, forming an abscess. In the earlier 
stages bacterial colonies, frequently of the colon bacillus, are found within 



DISEASES OF THE RENAL PELVIS. 



1047 



the tubules, the epithelium of which is necrotic, while the adjacent inter- 
tubular tissue is infiltrated with leukocytes. A granular degeneration of 
the epithelium of the convoluted tubules is associated. The remains of 
a previous pyelonephritis are at times to be found in various parts of the 
kidney as foci of fibrous tissue, in which the tubules and glomeruli have 
been obliterated. 

Symptoms. — The symptoms of pyelitis are often insignificant or sub- 
ordinate to those of the disease in which it occurs as a complication, and 
the existence of the affection is often determined by the examination of 
the urine alone. This is equally true in acute and in chronic pyelitis. 
There may be frequency of micturition, although this symptom is more 
suggestive of cystitis. There may be dull pain in the region of one 
or both kidneys, with sensitiveness on pressure, or the pain is more 
severe, following the course of one or both ureters. There may be but 
little constitutional disturbance if the inflammation is limited to the 
mucous membrane of the renal pelvis. The urine in simple pyelitis 
presents a normal color and specific gravity, and has an acid reaction. 
The percentage of albumin is small, and corresponds to the quantity of 
pus present. The sediment also varies in quantity according to the 
amount of pus present, which is more abundant in chronic than in acute 
pyelitis. The sediment contains pus- corpuscles, few or many red blood- 
corpuscles, and epithelial cells in considerable number. The epithelial 
cells from the pelvis of the kidney have no characteristics either of 
shape or of arrangement by which they are to be discriminated from 
those of the bladder. If the pyelitis is limited to one kidney, the flow 
of purulent urine may be followed by that of a normal urine from tempo- 
rary obstruction of the ureter continuous with the diseased renal pelvis. 
Within the last few years the diagnosis of such a limited pyelitis in the 
female has been repeatedly accomplished by catheterization of the ureters, 
a method of diagnosis made familiar by Kelly, of Baltimore. 

The onset of a pyelonephritis is indicated by the occurrence of chills, 
fever, and sweating, in addition to the possible pain in the region of the 
kidneys and ureters. The frequent recurrence of the chills often suggests 
a malarial fever, although they occur without periodicity. The disturb- 
ances of appetite and digestion and of the nervous system characteristic 
of fever are associated. In addition to the characteristics of the urine 
already mentioned, hyaline and epithelial casts and renal epithelium are 
to be found. The urine is more likely to be alkaline in pyelonephritis 
than in pyelitis, since the decomposition of retained m ine is a most 
important factor in its production. 

Diagnosis. — The diagnosis of pyelitis is often to be made by the 
recognition of pyuria, which may be the sole symptom. In such cases 
the acid character of the urine and the absence of vesical tenesmus are 
sufficient to indicate the source of the pus. In chronic pyelitis, especially 
when there is polyuria, the symptoms are somewhat suggestive of 



1048 



DISEASES OF THE URINARY APPARATUS. 



fibrous nephritis, but there is often persistent pain in the region of the 
kidney. The diagnosis of pyelitis with dilatation of the pelvis of the 
kidney will be considered under pyonephrosis. 

Prognosis. — The prognosis of pyelitis depends largely upon the 
ease with which the cause can be removed. It is, therefore, favorable in 
the infectious diseases and when the inflammation is the result of toxic 
irritants, but when the removal of the irritant demands a surgical opera- 
tion the prognosis becomes more grave. The prognosis of a pyelone- 
phritis is also grave, especially when it occurs in a person in whom, in 
virtue of prolonged obstruction to the escape of urine from a stricture 
or an enlarged prostate, chronic disease of the urinary tract has preceded 
the occurrence of pyelonephritis. Even in such cases the patient may 
recover, although a permanent atrophy of the kidney results. 

Treatment. — The treatment of pyelitis depends mainly upon its 
cause. Under all circumstances the greatest care should be exercised to 
prevent chilling of the surface, and in acute or subacute cases confinement 
to bed is essential. The food should be always largely farinaceous, and 
in many cases trial of absolute milk diet should be made. In times of 
exacerbation the long-continued lukewarm bath often acts favorably. 
Astringent remedies are rarely of any value, but when the discharge is 
excessive, gallic acid will sometimes reduce the amount in cases of recent 
date and of moderate intensity, in which class of cases buchu, salol, and 
especially uva ursi, or, better, its active principle, arbutin (from twelve 
to twenty grains a day), may also be tried in large doses. 

In older cases with much suppuration boric acid may be employed 
(ten grains from three to six times a day in diluted watery solution), 
or the more stimulating remedies, such as oil of copaiba, oil of sandal 
wood, and even oil of turpentine, may be given in ascending doses. If 
in any case the urine is strongly acid, very dilute solutions of alkalines 
may be used. Commonly the patient should be encouraged to drink very 
freely of water. 

It is evident that in a large number of cases pyelitis depends upon a 
cause which is not to be relieved by medical treatment, and must come 
under the notice of the surgeon. When there is stricture, it should be 
attended to without delay ; if in any case the tumor becomes perceptible 
and the symptoms are severe, there should be immediate surgical explo- 
ration, followed by such operation as may seem advisable. (See also 
Eenal Calculi and Tubercular Kidney.) 

HYDRONEPHROSIS AND PYONEPHROSIS. 

Definition. — Dilatation of the pelvis of the kidney, the contents of 
the dilated pelvis being urine alone, hydronephrosis, or mixed with pus, 
pyonephrosis. 

Etiology. — The chief cause of the dilatation is prolonged obstruction 
to the outflow of urine, which may be occasioned by contraction, com- 



DISEASES OF THE RENAL PELVIS. 



1049 



pression, or obstruction of the urinary tract at any point below the pelvis 
of the kidney, and may affect one or both pelves. Contraction is the 
result of inflammation of one or both ureters, which may end in oblit- 
eration of the canal. Obstruction to the outflow of urine may be due to 
congenital causes, as atresia, valvular folds, twists, or oblique insertion of 
the ureter, but more important are the acquired causes of obstruction, as 
inflammatory processes around the ureter, a displaced uterus, and uterine, 
ovarian, or rectal tumors compressing or constricting the ureters. Ob- 
struction may also be the result of causes acting from within the urinary 
tract, as inflammation, stricture, enlarged prostate, calculi, and tumors. 
The occasional occurrence of hydronephrosis without recognizable ob- 
struction is to be borne in mind. 

Pyonephrosis arises when the dilated renal pelvis becomes the seat 
of a suppurative inflammation. On the other hand, a chronic pyelitis 
may result in dilatation of the renal pelvis, with associated atrophy of 
the kidney, either from a weakening of the wall of the renal pelvis or 
from obstruction, perhaps temporary, to the outflow of urine. 

Morbid Anatomy. — A cystic tumor results, occupying the site of the 
kidney, and assuming its shape, but perhaps large enough to appear as 
an abdominal tumor containing several gallons of fluid. The larger its 
size the more likely are the abdominal organs to be displaced, and the 
colon may lie upon the tumor or at one side. It is composed chiefly 
of the dilated renal pelvis and calices, the more or less atrophied kidney 
appearing as an appendage to the former, and the larger the tumor the 
greater is the degree of atrophy of the kidney. The interior of the 
sac shows communicating sacculi, the dilated calices, at the bottom of 
which the flattened pyramids are to be recognized. Chronic interstitial 
nephritis arises as the dilatation progresses, and the liquid contents of 
the cyst present the characteristics of the urine in this affection. The 
contents are essentially a urine of low specific gravity, although in 
hydronephrosis of long duration uric acid and urea may be absent. 
There is usually no sediment, but blood, pus, fat, cholesterin, or chalky 
material may be present in virtue of complicating hemorrhage or in- 
flammation. If the obstruction is in the ureter, the latter may become 
so dilated as to suggest the small intestine. In pyonephrosis the sac 
contains pus in addition, and instead of the smooth and shining grayish- 
white wall of hydronephrosis there is a rough, opaque yellow, perhaps 
granular or ulcerated, wall. 

Symptoms. — In general the symptoms of hydronephrosis are due to 
the resulting tumor, and eventually to the associated fibrous nephritis. 
The usually gradual formation of a tumor produces no disturbance until 
a considerable size has been attained. In unilateral hydronephrosis the 
sound kidney excretes a normal urine, while in bilateral hydronephrosis 
the urine may be normal until towards the close of life, when it presents 
the characteristics of interstitial nephritis. In such eases the frequently 



1050 



DISEASES OF THE ITPENAPY APPARATUS. 



associated hypertrophied heart is compensatory and prevents oliguria. 
Cases of intermittent hydronephrosis are to be recognized, in which 
temporary obstruction to the outflow of urine takes place, the rapid 
formation of the tumor being associated with pain in the region of the 
affected kidney. There is temporary diminution in the quantity of 
urine passed, with perhaps vomiting and fever, lasting a few days, when 
relief follows the evacuation of a considerable quantity of urine in which 
blood may be present. The tumor is unilateral or bilateral, according 
as the obstruction affects one or both ureters, and, even if but one kid- 
ney is involved, may fill the greater part of the abdomen. The tumor 
is resistant, and when small may descend with the diaphragm ; its sur- 
face is smooth, and a sense of fluctuation is more or less distinctly trans- 
mitted. When the colon crosses the tumor the former, if empty, may be 
felt as a movable cord, and can be distended by inflation of the intestine. 
The larger the tumor the more likely is the colon to be displaced later- 
ally. The tumor may produce the sensation of fluctuation, occasion 
pain extending into the thigh, cause persistent constipation, or give 
rise to dyspnoea by interfering with the movements of the diaphragm. 
The tumor in pyonephrosis rarely attains so large a size as that of 
hydronephrosis. If the obstruction is intermittent in character, the 
diminution in the size of the tumor is associated with the presence of 
pus, blood, and albumin in the urine. In persistent pyonephrosis the 
symptoms are those of a suppurative pyelitis. The evacuation of the 
tumor, whether the latter is due to the presence of urine or of pus, may 
take place into the intestine, pleural cavity, or lung. As a rule, with 
the progressive enlargement in double hydronephrosis symptoms of 
chronic uraemia occur, the urine presenting the characteristics of that 
of chronic fibrous nephritis. 

Diagnosis. — Persistent hydronephrosis progresses as an abdominal 
tumor, the renal nature of which may be suspected from the seat, espe- 
cially when the colon lies in front. The greater the size of the tumor, 
the more likely is it to be confounded with cystic or solid enlargements 
of the abdomen, whether of renal, hepatic, ovarian, or ascitic character. 
The tumor of pyonephrosis presents similar physical characteristics, and, 
except that it rarely attains so large a size, may also be confounded 
with other abdominal tumors, but is more likely to be mistaken for a 
circumscribed peritonitis, especially when in the right half of the ab- 
domen or with a paranephric abscess. The presence of pus in the mine 
may serve to exclude a circumscribed peritonitis, while aspiration may be 
necessary to determine the cystic nature of the tumor, and thus to differ- 
entiate it from solid abdominal tumors, and to permit an examination of 
the fluid, the renal origin of which is usually indicated by the presence 
of urea and uric acid. Even aspiration may fail to establish a correct 
diagnosis in unilateral hydronephrosis of long standing in which the 
kidney has been practically destroyed. 



DISEASES OF THE RENAL PELVIS. 



1051 



Prognosis. — Unilateral hydronephrosis may produce purely me- 
chanical discomfort. Bilateral hydronephrosis, when progressive, has 
an unfavorable prognosis, essentially that of chronic fibrous nephritis. 
Bapidly fatal termination may follow the rupture of the sac in either 
variety of hydronephrosis. 

Treatment. — Congenital hydronephrosis when bilateral cannot be 
reached by any treatment. When unilateral it may be palliated by tap- 
pings—an operation, however, which involves serious risk of rupturing 
the sac or of producing peritonitis. In rare cases the fluid can be forced 
out by manipulation of the abdominal walls. Surgical operation with 
the purpose of relieving the kinks or twists of the ureter, or of removing 
other remediable obstructive causes of the disorder, or of removal of the 
kidney itself, is certainly justifiable, but there are at present no reliable 
surgical statistics. 

Acquired hydronephrosis has been relieved by massage, with a sudden 
discharge of the urine and immediate subsidence of the tumor ; but some 
danger attends the massage, and too much force may rupture the sac. 
Aspiration affords temporary relief, and has by repetition produced cure 
in recorded cases. The aspirating needle (not trocar) should be inserted 
on the right side, two and a half inches behind a line perpendicular 
to the anterior superior spine of the ileum, and midway between the 
crest of the ileum and the last rib. On the left side the needle should be 
inserted about an inch higher up. Nephrotomy, which has been per- 
formed in a number of cases, seems to be very rarely if ever fatal, but 
in more than fifty per cent, of the cases produces a permanent fistula. 
(Bruce Clarke.) Nephrectomy, according to the statistics of Newman, 
has had a mortality of forty-one and three-tenths per cent. 

Intermittent hydronephrosis often does not cause serious symptoms, 
and in such cases should be left to nature. When it is due to a movable 
kidney, and consequent kinking of the ureter, it may be relieved by 
nephrorrhaphy. 

In pyonephrosis, as soon as the existence of pus has been determined 
by aspiration, nephrotomy by a lumbar incision should be performed ; 
almost invariably nephrectomy is ultimately necessary, but the result is 
undoubtedly better when the major operation is deferred until the patient 
has recovered from the pysemic condition produced by the pyonephrosis. 

SUPPURATIVE PARANEPHRITIS. PERINEPHRIC OR PARANEPHRIC 

ABSCESS. 

Definition. — A purulent inflammation of the fat-capsule of the 
kidney. 

The importance of the recognition of an abscess in the fat-tissue sur- 
rounding the kidney makes it desirable to give separate consideration to 
this condition, which frequently is the result of disease of the kidney, 
although it may arise from other sources. A certain degree of contusion 



1052 



DISEASES OF THE URINARY APPARATUS. 



in the exact designation of the process has arisen from the failure to 
discriminate between the fibrous and the fat capsule of the kidney. The 
former may be inflamed, perinephritis, even acutely, but contains no 
extensive accumulation of pus, nor does any large abscess ever lie be- 
tween the kidney and its fibrous capsule. The fat capsule of the kidney, 
on the contrary, is continuous with the subperitoneal fat-tissue, and fre- 
quently becomes the seat of extensive suppurative inflammation, which 
has been commonly called a perinephritic abscess, although there may be 
no inflammation either of the kidney or of its fibrous capsule. Para- 
nephritis may be acute or chronic, the former being characterized by the 
presence of pus, the latter resulting in the formation of fibrous tissue. 

Etiology. — This affection occurs twice as often in men as in women, 
and more frequently in adult life than in youth. Its origin is never 
spontaneous, though it may be so concealed as to receive this term, but 
represents the extension of an inflammatory process from elsewhere, 
usually from the immediate vicinity. It may follow a wound, as from a 
knife or a bullet. It often occurs from the extension of a suppurative 
nephritis or pyelitis, appendicitis, septic thrombosis or lymphangitis fol- 
lowing parturition or operations upon the pelvic organs, testes, or sper- 
matic cord, abscesses of the liver and suppurative perihepatitis, caries of 
the spine or pelvis, and suppurative inflammation of the lungs or pleura. 
Suppurative paranephritis may also occur in the sequence of infectious 
diseases, as typhus and typhoid fevers and small-pox. This affection most 
frequently occurs in suppurative nephritis and chronic renal tuberculosis. 

Morbid Anatomy. — Inflammation of the fat- tissue rapidly results in 
the formation of pus, and the peritoneum is separated from the fibrous 
capsule of the kidney by a trabeculated cavity with ragged walls and 
communicating sinuses containing pus, blood, and sloughs. In the fur- 
ther progress of the inflammation the abscess extends both upward and 
downward, and perforation may occur in the loin, perineum, or groin, or 
into the renal pelvis, bladder, colon, duodenum, or the peritoneal or 
pleural cavity. 

Symptoms. — The onset of a suppurative paranephritis is usually ob- 
scure, since this affection occurs as a complication of a variety of well- 
characterized diseases in which fever is a common feature. The latter is 
often intermittent and associated with chills, and accompanied with loss 
of appetite and disturbed digestion, which favor progressive emaciation 
and debility. The patient suffers from thirst, the bowels are constipated, 
the pulse is feeble, and respiration may be quickened. Eventually the 
patient assumes a typhoidal aspect, especially if evacuation of the pus 
has not occurred. Pain and swelling are the localizing symptoms. The 
pain is in the region of the kidney, becomes aggravated on pressure, and 
may extend into the legs. The swelling is best appreciated on bimanual 
examination while the patient is in the dorsal position. It occupies the 
lumbar region, and the space between the lower ribs and the crest of the 



RENAL CALCULUS. 



1053 



ilium may distinctly bulge. The skin in this region may be congested 
and cedernatous, and a localized sensation of fluctuation may indicate 
the approximation of the abscess to the surface of the body. The urine 
may show merely a trace of albumin or a few red blood- corpuscles, as in 
congestion of the kidney. The presence of pus in the urine indicates an 
associated pyelitis, or, when sudden and in large quantity, the rupture 
of the abscess into the urinary tract. 

Diagnosis. — The nature of the painful tumor in the region of the 
kidney associated with fever is determined by an appreciation of the 
possible causes. Its position behind the peritoneum may be fixed by 
inflation of the colon. The appreciation of its exact nature may require 
aspiration, for the examination of the urine is of but little value. Sup- 
purative paranephritis on the right side originating from appendicitis, as 
a rule, is of sudden onset and rapid progress. 

Prognosis. — The outcome of a suppurative paranephritis is largely 
dependent upon the cause. If this is remediable, the prognosis is 
favorable, and recovery has followed both the absorption of the pus and 
its spontaneous evacuation. The latter result is favorable only when 
free drainage and freedom from sepsis concur. In the absence of these 
conditions death is likely to result from septicaemia, embolic abscesses, 
progressive emaciation and debility, or amyloid degeneration. 

Treatment. — Absolute rest, milk diet, saline purgation, or local 
depletion may possibly arrest a forming perinephric abscess, but so soon 
as there is reasonable ground for believing that pus is present, a free 
lumbar incision should be made and thorough drainage established. 

NEPHROLITHIASIS. RENAL CALCULUS. 

Definition. — The conditions associated with the formation of precipi- 
tates from the urine in the kidney or the renal pelvis. 

Several of the constituents of the urine may be precipitated in the 
urinary tract, especially in the pelvis of the kidney and in the bladder. 
The resulting sediment is accumulated in greater or less quantity, and 
is designated as sand, gravel, or stone, calculus, according to the size 
attained. The calculus is called renal when found within the kidney 
or its pelvis, and during its passage from the kidney to the bladder. 

Etiology. — Calculi occur more often in men than in women, and 
most frequently in children and elderly persons. Heredity, locality, and 
sedentary and luxurious habits appear to be favorable to their formation. 
They are frequent in gout, and, though often a cause of chronic pyelitis, 
they may be a result of that disease. The immediate cause of the for- 
mation of calculi is uncertain, although clots, shreds of tissue, or the 
ova of parasites may serve as nuclei. 

Composition and Appearances. — Uric acid and the urates, either 
separately or together, calcic oxalate, calcium phosphate, the triple 
phosphates, calcium carbonate, cystin, xanthin, and indigo, may be pre- 



1054 



DISEASES OF THE URINARY APPARATUS. 



cipitated. Phospliatic calculi usually have a nucleus of uric acid or 
of calcic oxalate. The calculi of uric acid, calcic oxalate, and phos- 
phates are relatively common ; the other varieties are very rare. The 
phosphatic calculus is present in alkaline, the others in acid, urine. Cal- 
culi may occur in one or both kidneys, are single or many, as many 
as a thousand having been found in one renal pelvis, and vary in size 
from that of a grape-stone up to that of a goose-egg. They may be round 
or smooth, granulate or spinous, or be irregularly branching with protu- 
berant knobs projecting into the dilated calices. Uric acid calculi are 
yellow, red, or brown in color, and lamellated when broken. The calcic 
oxalate or mulberry calculus is dark brown and dense. Phosphatic 
calculi are gray, friable, somewhat porous. Cystin forms a calculus 
resembling wax. Xanthin appears as a hard brown calculus, indigo as 
a dark-blue mass. 

The renal calculus is usually associated with dilatation of the pelvis 
of the kidney, sometimes extreme, and pyelitis. Pyelonephritis, sup- 
purative paranephritis, and atrophy of the kidney, may occur. 

Symptoms. — Penal calculi maybe present and produce no symptoms. 
Gravel, sand, or small calculi may be passed repeatedly through a period 
of years without discomfort. As a rule, however, disturbances are con- 
nected both with the presence and with the passage of the calculus. 

The presence of the calculus in the renal pelvis is usually indicated 
by lumbar pain and tenderness near the kidney concerned, hematuria, 
pyuria, and perhaps a tumor in the region of the affected kidney. The 
pain is rather a dull ache, more or less constant, though sometimes 
aggravated by motion. Although usually limited to the affected kidney, 
it may be referred to the sound kidney. Blood- corpuscles are frequently 
found in the urine, sometimes in sufficient number to produce discolora- 
tion. Pyuria is frequent, since pyelitis is the usual result of a calculus 
retained in the pelvis of the kidney. The quantity of pus is commonly 
small, and there may be intervals when none is passed. The existence 
of the pyelitis is also made evident by the occurrence of chills and fever. 
If the calculus obstructs the outflow of urine, dilatation of the pelvis of the 
kidney occurs, either a hydronephrosis or a pyonephrosis, according as 
pyelitis is absent or present. Abscesses of the kidney or paranephritis 
may follow the pyelitis, the latter being indicated by an increase in the 
size of the renal tumor and persistent elevation of temperature. If a 
chronic inflammation of the kidney results, symptoms of mild ursemia 
develop, or a prolonged cachexia from amyloid degeneration of the 
kidney may follow. 

The passage of the stone produces more characteristic symptoms. 
These are renal colic and hsematuria. The pain usually begins instan- 
taneously, especially during exertion, though it may arouse the patient 
from a sound sleep. It is cutting or stabbing, and is sharply defined, 
extending along the course of the ureter, either towards the testicle or 



RENAL CALCULUS. 



1055 



into the thigh. It may be most severe in the back, or may radiate 
upward, perhaps into the epigastrium. The pain may cease suddenly, 
either from the escape of the stone into the bladder or from its return 
to the pelvis of the kidney, and a recurrence of the paroxysm take place 
with the renewal of efforts at the expulsion of the stone. The attack of 
pain may be associated with a chill or chilliness and a sensation of faint- 
ness, and in children be accompanied with convulsions. The spasms of 
renal colic may last for an hour or more, or recurrent paroxysms be 
continued for many hours, with sudden relief if the stone enters the 
bladder. Hematuria associated with the attack of renal colic may be 
sufficient to produce a distinct redness of the urine and an appreciable 
bloody sediment, or merely a smoky color, and may persist for several 
days after the passage of the calculus. There is increased freciuency 
of micturition, and the quantity of urine passed may be either less 
or greater than normal. Earely there is suppression of urine lasting 
for days, although the stone is usually impacted in but one ureter. If 
the calculus is impacted in the ureter, ulceration, perforation, abscess, and 
peritonitis may occur. The patient prefers to lie on the affected side 
with updrawn knees, and the testicle on the affected side is frequently 
retracted and sometimes swollen when the pain extends into the scrotum. 

Diagnosis. — Eenal colic may be confounded with intestinal colic, 
and, when on the right side, with hepatic colic or the pain from perfo- 
rating appendicitis. Intestinal colic is not so sharply denned and more 
rapidly improves, while the frequent limitation of the pain to the course 
of the ureter, the hematuria, and the absence of localized extreme ten- 
derness exclude appendicitis ; the lack of jaundice and dilatation of the 
gall-bladder are important in eliminating hepatic colic. It is to be 
remembered that severe pain even in paroxysms, but without hematuria 
or the passage of calculi, may be referred to the region of the kidney 
and ureters. To such attacks, which are sometimes associated with a 
movable kidney, the term nephralgia is applied : patients suffering from 
them have been operated upon with a view to the removal of a probable 
calculus, although, according to Ransohoff, in forty-four recorded cases 
the surgeon has failed to find a calculus. In several instances, how- 
ever, the nephralgia, like the similar hepatalgia, has been relieved by 
the operation. The calculous nature of a pyelitis or a nephritis is to 
be suspected, in the absence of attacks of renal colic, from the persist- 
ence of pain limited to the region of the kidney, aggravated on motion 
and often associated with blood in the urine. Especial importance is to 
be attached to the persistent presence of red blood-corpuscles recog- 
nizable by the microscope. The finding in the urine of crystals is of 
little aid in the diagnosis of a calculus, though of value in determining 
the nature of a calculus which has been diagnosticated by other evidence. 

Prognosis. — An attack of renal colic rarely proves fatal, and succes- 
sive attacks may be borne without risk to the life and general good health 



1056 



DISEASES OF THE URINARY APPARATUS. 



of the patient. The occurrence of anuria is a serious complication, 
although recovery has taken place after its existence for twenty days. A 
calculus too large to pass through the ureter may be retained in the pelvis 
of the kidney without producing serious disturbance. There are no 
known means by which it may be dissolved while in the pelvis of the 
kidney, and its presence there is always a source of danger to the life and 
health of the patient, through the production of the serious inflammatory 
and degenerative conditions mentioned. 

Treatment. — In renal colic the patient should be put in a hot bath, 
and hypodermic injections of morphine should be given, with inhalations 
of ether or chloroform, as in biliary colic. Very hot fomentations over 
the seat of pain are usually grateful to the patient. Manipulations of the 
part do no good, but it is said that cases have occurred in which inversion 
of the body has been followed by slipping back of the stone and imme- 
diate relief. The drinking of large quantities of feebly alkaline water, 
or, if there be nausea, of carbonic acid water with potassium citrate and 
lemon juice, may be of service in lessening the renal irritation. 

The treatment of a patient suffering from habitual renal gravel or 
calculus depends largely upon the nature of the concretions. Whenever 
there is a calculus in the pelvis of the kidney, violent, especially sudden, 
exertions, jolts, or falls must be sedulously avoided, for fear of dislodging 
the stone and throwing it into the ureter. If the calculus be uric acid, 
the diet should be largely farinaceous ; if the calculus be oxalic acid, 
sweets and starchy food should be avoided. In all cases the habit 
should be formed of drinking large quantities of water between meals, 
two to three pints a day. In uric acid nephrolithiasis Saratoga, Vichy, 
or other alkaline mineral waters may be used ; they are, however, prob- 
ably inferior to artificial waters made by the addition of a known quan- 
tity of alkalies to carbonic acid water, — one or two drachms of sodium 
bicarbonate and twenty to thirty grains of potassium bicarbonate to 
the pint. Alkaline waters may often be advantageously substituted, 
especially in uric acid gravel, by the benzoated water given in formula 
4 5 it is very effective in removing uric acid, probably by converting it 
into hippuric acid. 

Although there is no sufficient reason for believing that calculus once 
formed in the kidney can be dissolved, nevertheless, in obedience to 
authority, trial may be made with alkaline solvents, — potassium citrate 
given well diluted to the extent of half an ounce a day, or piperazin in 
doses of fifteen grains three times a day, kept up for several months. 
This treatment is, however, not free from danger : not only may the 
general bodily condition be depressed by the long use of the alkali, 
but the continuous alkalinity of the urine may lead to deposition of the 
phosphate about the calculus. 

The only radical cure when stone is permanently lodged in the kidney 
is in surgical operation, — either nephrotomy, followed by the extraction 



DISEASES OF THE BLADDER. 



1057 



of the stone, or nephrectomy, the removal of the kidney. Nephrectomy 
should never be practised unless the kidney has undergone hopeless, 
secondary changes, a condition which should never be allowed to occur 
when the case comes under treatment sufficiently early. Persistency 
of attacks of renal colic may of themselves demand nephrolithotomy, 
but the appearance of pus in the urine or persistent albuminuria between 
the attacks should lead to its immediate performance. 

The value of the early operation as contrasted with the late is well 
shown in the statistics collected by Thorndike as contrasted with those 
of Newman and Legue. In one hundred and twenty- eight cases, in- 
cluding those with and those without marked purulent discharges, there 
were eighteen deaths following nephrolithotomy, giving a mortality of 
fourteen per cent., the majority of the deaths being in suppurative cases 
(Thorndike) ; in eighty-two cases free from suppuration, reported by 
Newman and Legue, the mortality was only two and four- tenths per cent. 
White gives the average mortality of nephrolithotomy at five per cent. 

DISEASES OF THE BLADDER. 

ENURESIS. INCONTINENCE OF URINE. 

Incontinence of urine is the result flf paralysis of the sphincter or 
of contraction of the compressor muscle of the bladder, in either case 
the bladder being unable to retain the urine. Paralytic incontinence is 
characterized by frequent micturition, often excited by sneezing, cough- 
ing, or other sudden general muscular action, and by more or less con- 
stant dribbling. Spasmodic incontinence is made evident by frequent 
micturition occurring at irregular intervals. Paralysis of the com- 
pressor muscle may also produce frequent micturition, perhaps constant 
dribbling, but the bladder becomes hyperdistended from retention, and 
voluntary muscular effort does not increase the rapidity of the outflow. 

The causes of incontinence of urine are general muscular or nervous 
weakness, disease of the spinal cord, faulty innervation of the bladder, 
excessive distention from obstruction or polyuria, cystitis, vesical calculi, 
and irritation of the genital tract or rectum. 

Enuresis is normal in infants ; it frequently occurs in young children, 
especially at night, nocturnal enuresis, and occasionally also during the 
day. Such children are sometimes pale, often excitable, but not infre- 
quently free from other disturbances. The escape of urine oftenest takes 
place during the early part of the night, the child usually being unaware 
of its passage. The inability to retain the water may be due to the habit 
of freely drinking milk or water before going to bed, to local irritation, 
as from worms in the rectum, to a vesical calculus, to concentrated or 
saccharine urine, to hyperesthesia of the neck of the bladder, to periph- 
eral irritation from phimosis or a narrow meatus, or to reflex irrita- 
tion, as teething. It is to be remembered that wetting the bed may be 

07 



1058 



DISEASES OF THE URINARY APPARATUS. 



the sole evidence of an epileptic fit during the night, and that it may 
be an early symptom of organic disease of the brain or cord. 

Treatment. — Functional nocturnal enuresis usually in the end yields 
to increase of age and of general bodily strength. The treatment should 
be primarily directed to the strengthening of the general system by 
tonics, by out- door exercise, and especially by strychnine j if the urine 
be acid and irritant, alkalies may be employed. Tincture of belladonna 
given in as large doses as can be borne in the latter part of the day is 
probably the most efficacious remedy. The child should avoid drink- 
ing in the evening, and should always be taken up at ten o'clock to 
empty the bladder : punishment is cruel. 

NEURALGIA OF THE BLADDER. IRRITABLE BLADDER. 

Frequent and painful micturition results from hypersesthesia of the 
neck of the bladder, which may be a symptom of organic disease, as in- 
flammation or calculus, or may exist without apparent cause, constituting 
irritable bladder. The hyperesthesia of the neck of the bladder is then 
attributable to an enfeebled nervous system from faulty hygienic sur- 
roundings, digestive disturbances, sexual excess, and uterine or ovarian 
disease. The frequency of micturition is accompanied with tenesmus, 
an insuperable desire to pass water. There is usually pain at the end 
of micturition, and a sense of discomfort in the perineum or symphysis 
before and after micturition. When the pain is due to spasm of both 
compressor and sphincter muscles it may be so intense as to cause symp- 
toms of collapse, the skin being covered with a cold sweat and the pulse 
quickened and enfeebled. The passage of a sound produces distress when 
the hypersesthetic region is reached. Patients suffering from an irritable 
bladder are usually thin and pale, and complain of headache, backache, 
and physical weakness. They are often irritable or depressed, and suffer 
readily from imaginary evils. 

Treatment. — In most cases of irritable bladder attention should be 
chiefly directed to the relief of the neurasthenia which is at the base of 
the complaint. Not rarely extremely acid urine or local disease exists, 
and should be appropriately remedied. Suppositories of extract of bella- 
donna or opium are efficient in violent paroxysms, and may, if necessary, 
be aided by local hot baths. Belladonna given continuously may be of 
service, and sometimes treatment as for a mild cystitis is judicious. 

cystitis, inflammation of the bladder. 

Etiology. — The causes of inflammation of the bladder are both gen- 
eral and local, although such a distinction is not always to be absolutely 
made. Most important among the former are the infectious diseases, 
especially typhoid fever, acute articular rheumatism, pyaemia and septi- 
caemia, erysipelas, influenza, mumps, scarlet fever, and small-pox, in 
which slight degrees of cystitis are frequent. In these diseases also the 
milder varieties of acute nephritis are common, and the inflammation of 



DISEASES OF THE BLADDER. 



1059 



the bladder, like the nephritis, is probably the result of the local action 
of the bacteria or toxins demonstrably or presumably concerned in the 
origin and progress of these diseases. The frequent association of cystitis 
and gout is most satisfactorily explained as the result of a direct irrita- 
tion by the concentrated urine of the mucous membrane of the bladder. 
The more purely local causes are injuries to the bladder, which may 
result from the use of instruments or of irritating urethral injections, or 
from the pressure of faeces in the rectum, of pessaries in the vagina, or 
of the foetal head at childbirth. Also important among the local causes 
are foreign bodies, including calculi and invading bacteria, especially the 
gonococcus. Certain medicinal agents, as cantharides, copaiba, cubebs, 
and mustard, when absorbed and eliminated by the kidneys, may produce 
a cystitis. Eetention of urine, whether induced by stricture, prostatic 
enlargement, or vesical tumors, or by defective muscular contraction, as 
in paraplegia, is capable of exciting a cystitis. Inflammation of the 
bladder may also be occasioned by the extension of an inflammatory 
process from neighboring parts, as the urethra, rectum, uterus, vagina, 
or peritoneum, as is illustrated in the use of an unclean catheter. 

Morbid Anatomy. — The anatomical changes to be found are either 
characteristic of a catarrhal inflammation or are indicative of a pseudo- 
membranous or a phlegmonous process. In acute catarrhal cystitis the 
mucous membrane is reddened and swollen and the contents of the 
bladder are either slimy or purulent, in accordance with which differ- 
ences a cystitis is regarded as catarrhal or suppurative. In chronic cys- 
titis the mucous membrane is of a bluish slate color in spots, and the 
contents of the bladder are more slimy than purulent. The pseudo- 
membranous cystitis is characterized either by the presence of fibrinous 
clots, or more frequently by ecchymoses, ulcerations, and superficial ne- 
croses of the mucous membrane, diphtheritic cystitis. These necroses 
appear as opaque gray or yellow patches, especially at the neck of the 
bladder and upon projecting folds of mucous membrane, and may con- 
tain urinary salts. In phlegmonous cystitis the submucous tissue is 
destroyed, and the mucous membrane may be detached in shreds or 
flakes, or even be exfoliated as a cast of the interior of the bladder. 

Symptoms. — The earliest as well as the most distressing and per- 
sistent symptom of inflammation of the bladder is pain. This may be 
preceded by a chill and fever, and the latter may last for some time 
during the progress of the acute inflammation. The pain is usually 
referred to the region of the symphysis pubis, but may extend to the 
perineum and the rectum, and is somewhat relieved by micturition. 
More severe and distressing is the frequently associated vesical tenes- 
mus, when intense called strangury, compelling frequent micturition, 
perhaps every few minutes, at the end of which a few drops of blood 
may escape. The urine is opaque, high-colored, and acid or alkaline. 
At the outset it maybe free from albumin, although later albumin occurs 



1060 



DISEASES OF THE URINARY APPARATUS. 



in consequence of the presence of blood or pns. A grayish sediment, 
the so-called mucous cloud, is formed, in which are particles of slime, 
giving the reaction of nucleoalbumin (mucin), and numerous poly nuclear 
leukocytes, cells of vesical epithelium, occasional red blood-corpuscles, 
and often abundant bacteria. If the urine is alkaline the precipitate 
usually contains amorphous phosphates, crystalline triple phosphates, 
and ammonium urate. In the severer forms of acute cystitis blood and 
albumin are abundant, and clots of fibrin or shreds of tissue may be 
present. The presence of casts and a higher percentage of albumin 
than is accounted for by the presence of pus and blood are indicative 
of a complicating inflammation of the kidney. 

In the milder varieties of acute cystitis the fever subsides in the 
course of a few days. Vesical pain and tenesmus gradually disappear, 
and the urine becomes normal. In chronic catarrhal cystitis the vesical 
pain and tenesmus may be comparatively slight. The opacity of the 
urine becomes greater and the sediment more abundant, containing larger 
numbers of pus-corpuscles and a correspondingly increased amount of 
albumin. The urine is usually alkaline, and the pus is often trans- 
formed into a gelatinous mass, which adheres to the vessel in which it is 
contained. Digestive disturbances, with slight loss of flesh and strength, 
often result from chronic catarrhal cystitis. 

The severer forms of acute cystitis may be such from the outset, or 
may be due to an acute exacerbation in chronic cystitis, and usually 
represent the result of a diphtheritic or gangrenous inflammation of the 
mucous membrane, or the extension of the inflammation to the subperi- 
toneal and paracystic fibrous tissue. The severity of the symptoms may 
be also due to a complicating pyelonephritis. The febrile disturbance is 
greater, the course is irregular, and the range of temperature is higher, 
with frequent wide daily variations between the extremes. The patient 
may be delirious, somnolent, or in a condition of stupor. The forma- 
tion of abscesses is indicated by localized induration, pain, and tender- 
ness, often apparent on rectal examination. The abscess may be evacu- 
ated into the bladder, with relief to the pain and discomfort, or may 
extend towards the peritoneum, with the production of a peritonitis. 
Sloughs of mucous membrane may plug the urethra, so that in the 
female they may be withdrawn by forceps. With the continuance of 
the severe symptoms the patient may collapse, the temperature being 
subnormal and the pulse inappreciable. Englisch and, recently, Paul 
Thorndike have called especial attention to the occurrence of prevesical 
inflammation in the space defined by Eetzius as in part the result of 
cystitis, the characteristic localizing symptom being a sharply defined, 
usually symmetrical tumor above the symphysis, terminating in suppura- 
tion, although sometimes undergoing resolution. 

Diagnosis. — Vesical pain and tenesmus suggest inflammation of the 
bladder, and the diagnosis is confirmed by examination of the urine. 



DISEASES OF THE BLADDER. 



1061 



Prognosis. — The longer the continuance of the cystitis the more 
doubtful is the prognosis. Becovery readily takes place in the milder 
varieties of acute catarrhal cystitis, whereas the prognosis becomes grave 
if the cystitis extends towards the kidney or to the neighboring fibrous 
tissue. The prognosis in chronic cystitis is always serious, from the 
frequent impossibility of removing the cause, and from the liability to 
acute exacerbations. 

Treatment. — Whenever from the existence of disease of the spinal 
cord, or from other cause, there is reason to fear the development of 
cystitis, the greatest care should be exercised to remove, if possible, the 
existing cause. Before beginning an habitual catheterization, boric acid 
or salol may be exhibited, so as partially to sterilize the urine. The 
catheters should be preferably of rubber, and should be kept in a bichlo- 
ride solution, and washed in hot water after use ; as the catheter goes 
through the urethra a solution of bichloride, 1 to 4000, should be sent 
through it so as to disinfect the urethra. The bladder should then be 
washed out with a strong solution of common salt (a large tablespoonful 
to a quart), and afterwards followed by a solution one-fourth as strong. 
After a time, when catheterization is daily practised, the tissues become 
so hardened and difficult of infection that absolute asepsis as to the 
catheter is all that is required. 

In acute cystitis the patient should be put to bed with the hips slightly 
elevated and the knees bent over a pillow, and given a mild, non- irri- 
tating diet from which all spices and alcoholic drinks are assiduously ex- 
cluded. When the symptoms are severe, absolute milk diet should be 
insisted upon. In order to render the urine as little irritating as possible, 
water should be taken very freely between meals, in the form either of 
the natural mineral water or of medicated waters, the selection being 
in accordance with the character of the urine : if this be ammoniacal, 
boric or benzoic acid may be given ; if it be irritatingly acid, alkalies 
should be used. When there is a large amount of uric acid, especially 
if there is gravel, formula 4 may be employed. In very severe asthenic 
cases, especially when there are excessive tenesmus and irritation of 
the neck of the bladder, the perineum should be freely leeched. The 
warm sitz-bath, or fomentations with hot water, often are very useful : 
poultices are uncleanly, and have no special advantage. Hot- water 
enemata sometimes do good, and should always be used where there is 
constipation. If such local applications fail to give relief, opium sup- 
positories, or preferably suppositories containing extract of opium (one 
grain) and extract of belladonna (one-quarter grain), may be tried. 
Barely hypodermic injections of morphine are necessary. Opiates are 
to be avoided if possible, and belladonna given by the mouth may be all 
that is required. Various drugs whose active principles are eliminated 
by the urine have been employed for the purpose of affecting tin 4 mucous 
membrane of the bladder. They should always be given in dilute solu- 



1062 



DISEASES OF THE URINARY APPARATUS. 



tion. The older of these remedies are uva ursi (fluid extract one tea- 
spoonful every three hours), or arbutin, its active principle (fifty to 
eighty grains a day), buehu (fluid extract one teaspoonful every three 
hours), triticum repens (fluid extract one teaspoonful every three hours ; 
very little value). Salol, or preferably sodium salicylate, is often given, 
forty to fifty grains a day ; potassium chlorate is especially commended 
by Strumpell, twenty grains of it dissolved in at least six ounces of water 
being administered three to four times in the twenty-four hours. 

When cystitis becomes subacute or chronic the stimulating diuretics 
are often serviceable : they are oil of cubeb, oil of copaiba, oil of sandal 
wood, terebene, and even oil of turpentine. In acute inflammatory con- 
ditions of the bladder these remedies are harmful. 

If in acute cystitis relief be not obtained in from twenty-four to forty- 
eight hours, the bladder should be washed out. Sometimes simple ster- 
ilized warm water suffices. In our experience a solution of boric acid (ten 
grains to the ounce to four per cent, (saturated) solution) has been espe- 
cially efficient, but other substances (see Chronic Cystitis) may be used. 
In chronic cystitis, after a careful examination of the parts, and the re- 
moval of any strictures, calculi, or other removable cause of irritation 
of the bladder, the chief reliance must be placed upon local irrigation. 
Boric acid, or corrosive sublimate 1 to 15,000, or plumbic acetate 1 to 
1000, or tannic acid 1 to 300, or carbolic acid 1 to 500, or alum 1 to 2000, 
maybe employed. Silver nitrate, in one-half to two percent, solution, 
is, according to the opinion of various surgeons, the most generally 
efficacious of all the local applications. In many cases, however, it pro- 
duces great pain, and it should therefore be first used in small quan- 
tities and in the weakest solution ; but it should be tried persistently. 
In washing out the bladder it is better never fully to distend the viscus j 
when the soft rubber catheter has reached the bulbo-membranous portion 
of the urethra, sterilized water should be sent through it by means of a 
fountain syringe and allowed to flow back, so as to wash out the urethra. 
The catheter should then be passed into the bladder, and from one to two 
ounces of fluid injected and afterwards withdrawn. About the same 
quantity should be injected various times until the viscus is thoroughly 
cleansed. To prevent absorption, the final washing should be with 
simple sterilized water. We have seen serious poisoning from the use of 
the saturated solution of boric acid. In most cases the character of the 
medicated solution should be varied from time to time. 

When a cystitis depends upon spinal paralysis, very little can be 
achieved by any local treatment. As the urine is always ammoniacal, 
boric, benzoic, and other acids given by the mouth are often very useful. 
Sodium hyposulphite in half-drachm doses has been especially recom- 
mended in hopeless cases. Draining the bladder through a suprapubic 
or peroneal opening, as practised by some surgeons, is justified only 
when the cystitis is threatening life or is due to local obstruction. 



FORMULARY. 



The following formulae are given largely as examples to medical students and young 
graduates to aid them before they have thoroughly acquired the art of extemporaneous 
prescription writing. They are not to he slavishly followed, but to be altered, modified, 
or entirely substituted by other combinations to suit the individual case. With very few 
exceptions they have, however, been much used in practice, and we believe are trust- 
worthy as practical working prescriptions. 



No. 1. 

Tr. guaiaci ammoniatae, f£>vi ; 
Tr. ferri chloridi, f^iss ; 
Tr. cantharidis, TT^xlviii; 
Vini aloes, f£vi ; 
Alcoholis, q. s. ad f^iii. 
M. S. — Teaspoonful after meals in milk. 

The proportions of this formula must be 
modified for the individual case. The aloes 
should be increased or lessened, as may be 
required, until the patient has one or two 
softish stools each day. There is also much 
difference in the irritability of the bladder 
in relation to cantharides. 

No. 2. 

]J Sodii sulphatis, 

Magnesii sulphatis, aa 3m" ; 

Aquae, f^vi. 
Misce. 

S. — Half to one ounce three or four times a 
day in a glass of water. 

No. 3. 

U Sodii sulphatis, 

Magnesii sulphatis, aa 3^iii ; 

Ferri sulphatis, gr. viii ; 

Aquas, f^vi. 
Misce. 

S. — Half to one ounce in water three or four 
times a day in a glass of water. 

No. 4. 

$ Lithii benzoatis, 

Lithii bicarbonatis, aa gr. xv ; 

Potassii bicarbonatis, gr. xx; 

Aquae acidi carbonici, Oi. 
Misce et dispensa in siphone. 
S. — Two pints daily. 

No. 5. 

U Bismuthi subcarbonatis. 3^iii ; 

Acidi carbolici, gr. xviii. 
Misce et dispensa in capsulis xxiv. 
S. — One or two every one to three hours, pro 
re nata. 



In making these capsules it is essential for 
the ingredients to be thoroughly incorpo- 
rated before being put in the capsules, which 
should also be kept well covered with some 
dry powder like lycopodium. In certain 
cases a mixture is preferred as follows : 

^ Acidi carbolici, gr. xviii ; 

Bismuthi subnitratis, £iii J 

Glycerini, f^ss; 

Aquae, f ^iiss. 
Misce. 

S. — Shake thoroughly to complete mixture. 
Dose, dessertspoonful in water. 

No. 6. 

R Acidi sulphurici aromatici, f^ii ; 

Ext. haematoxyli, 

Syr. zingiberis, f^iss. 
Misce et adde 

Tr. opii camphoratae, f^iss. 
S. — Dessertspoonful in water. 

In many cases it is well to diminish the 
amount of paregoric contained in this pre- 
scription, increasing proportionately the 
ginger syrup. 

No. 7. 

]J Antipyrini, gr. xv; 

Pilocarpinao hydrochloratis, gr. as; 

Tr. aconiti, gtt. viii ; 

Aquae, f^iss. 
Misce. 

S. — Take a tablespoonful, immediately followed 
by a hot general or foot bath (ten minutes) ; then, 
the patient being covered in bed, onu dessert- 
spoonful in a tumbler of hot toddy, repeated, if no 
sweating occur, in twenty minutes. When there 
is pain, if morphine does not disagree with the 
patient, one-sixth of a grain may be added to tho 
mixture. 

No. 8. 

U Mistura) creta?, f^iii ; 

Tr. kino, 

Tr. cinnamomi, 

Tr. opii camjthorataj, ail f^i. 
Misce. 

S. — Tablcspoonful in water, pro re nata. 

1063 



1064 



FORMULAE, Y. 



No. 9. 

]J Spiritus c amphorae, ss ; 

Olei caryophylli, TTL XXX > 

Chloroformi, f^iii J 

Tr. opii deodoratae, f^ii ; 

Tr. capsici, f^ii. 
Misce. 

US. — Shake well. Thirty to forty drops in 
water every half-hour to two hours, pro re nata. 



No. 10. 

U Tincturae ferri chloridi, f^ii ; 

Hydrargyri chloridi corrosivi, gr. ii; 

Glycerini, f£ix ; 

Aquae, f^ii. 
Misce. 

S. — Teaspoonful in water after meals. 

The amount of corrosive sublimate in this 
prescription may be increased or diminished 
according to the needs of the individual 
case. 

NO. 11. 

]J Potassii iodidi, ^ssj 

Syr. sarsaparillse comp., 

Ext. sarsaparillae fid. comp., aa f ^iii. 
Misce. 

S. — Teaspoonful to tablespoonful in water as 
directed. 

To the above formula corrosive sublimate 
may be added as desired ; no precipitate will 
be formed. 

No. 12. 

Bismuthi subnitratis, £i J 
Antipyrini, gr. x ; 
Cocainse hydrochloratis, gr. iiij 
Mucil. acaciae, 
Aquae, aa f^ss. 
Misce. 

S. — Shake well. Throw, by means of an ordi- 
nary dropper, about five minims into each nostril 
every two or three hours. 



No. 13. 

Allen' 8 Antiseptic Nasal Wash. 

Acidi benzoici, 
Sodii boratis, aa gr. lxxxv ; 
Acidi salicylici, gr. xx ; 
Acidi borici, £iv ; 
Thymoli, gr. xvi ; 
Eucalyptoli, gtt. viii; 
01. gaultheriae, gtt. viii; 
Mentholi, gr. v ; 
01. pini, gtt. viii ; 
Glycerini, £v, TTlxx; 
Alcoholis, giv; 
Aquae destill., q. s. ad ^xvi. 
Misce. 

S. — Add a teaspoonful to four ounces of water, 
and use as a spray or wash. 



No. 14. 

Setter's Antiseptic Nasal Wash. 

J£ Sodii bicarbonatis, ^i; 
Sodii boratis, ^i ; 
Sodii benzoatis, 
Sodii salicylatis, aa gr. xx ; 
Thymoli, 

Eucalyptoli, aa gr. x ; 
Mentholi, gr. v; 
01. gaultheriae, gtt. vi ; 
Glycerini, 
Alcoholis, 



jvmss ; 
Jii; 

Aquae, q. s. ad Oxvi 
Misce. 



This wash is very stimulating to the nasal 
mucous membrane, and often needs dilution. 

For practical purposes it is often much 
more convenient to have this solution in the 
form of tablets. All that is necessary for 
this purpose is to omit the glycerin, alcohol, 
and water from the above prescription, and 
divide the other ingredients, after thorough 
incorporation, into one hundred and twenty- 
eight tablets, one of which dissolved in two 
ounces of water will give a solution practi- 
cally of the strength of that of the formula. 

Another alkaline wash much used for 
cleansing the nose is DobeWs solution, which 
is composed of — 

U Sodii boratis, 

Sodii bicarbonatis, aa %i ; 

Acidi carbolici, gr. xxx ; 

Glycerini, f^i ; 

Aquae, Oii. 
Misce. 

No. 15. 

A powder for use by asthmatics may be made 
by taking out all the pieces of stems and leaf- 
stems from stramonium, so as to use only the 
leaves themselves, powdering these sufficiently 
fine to go through a No. 8 sieve, and then satu- 
rating thoroughly this powder with a saturated 
solution of potassium nitrate, and drying. 



No. 16. 

Potassii citratis, ^i ; 
Succi limonis, f^iss; 
Syr. ipecacuanhas, f^ss ; 
Syrupi, fgi. 
Misce. 

S. — Dessertspoonful every two hours. 

In this formula one grain of apomorphine 
hydrochlorate, or, if the patient be robust, 
half to one grain of tartar emetic, may be 
substituted for the ipecacuanha, the syrup 
beins; increased to an ounce and a half. 



FORMULARY. 



1065 



No. 17. 

J£ Ammonii chloridi, 

Ext. glycyrrhizae, aa, ^ii ; 
Mucil. acaciae, f^iss; 
Aquae, f^iiss. 

Misce. 

S. — Dessertspoonful every two hours. 
A simple solution of the ammonium salt 
in water is preferred by many patients, and 
is often more acceptable to the stomach. 

No. 18. 

]J Belladonnas fol., gr. xcvi j 
Hyoscyami fol., 
Stramonii fol., aa gr. xlviii ; 
Ext. opii, gr. iv ; 
Tabaci, gr. lxxx ; 
Aquae, Oi. 
M., ft. sol. et adde 

Potassii nitratis, gr. clx ; 
Potassii arsenitis, gr. cccxx. 
Saturate bibulous paper and dry for use. 
S. — Paper is rolled into cigarettes, oncof which 
is smoked until relief is afforded or some giddiness 
produced. 

No. 19. 

]J Sodii phosphatis, ^iii: 
Sodii sulphatis, ^i; 
Potassii iodidi, gi. 
Misce et fiat pulvis subtilissimus. 
M. S. — Teaspoonful to tablespoonful as re- 
quired. 

No. 20. 

U Pulveris sennae, ^ii; 

Pulveris zingiberis, ^i; 

Pulveris aloes, £ii. 
Misce. 

S. — Put in a pint of whiskey; agitate fre- 
quently, and after three days take the clear 
liquid at bedtime, thirty to sixty drops, more or 
less, as required to produce a free faecal discharge. 

If more convenient, the druggist can be 
directed to exhaust the powder with a pint of 
dilute alcohol. 

No. 21. 

R Ext. rhois glabrae fid., f^iii; 
Pulv. potassii chloratis, 5i ss 5 
Glycerini, f^ss. 
S. — Shake well. One to three teaspoonfuls to 
a wineglassful of water as gargle. 

No. 22. 

R Picis liquidae, f^iii ; 

Triturentur cum liquore calcis, Oviii, ad 
saturationem, et percolentur per prunum 
virginianam, ^viii. 
S. — Wineglassful one to two hours after each 
meal. 

No. 23. 

R Acidi nitrohydrochlorici, f£ii ; 

Aquae, f^iss; 

Strychninae sulph., gr. i. 
Misce et adde 

Tr. gentianae comp., 

Tr. cardamomi comp., aa q. s. ad f.^vi. 
S. — Dessertspoonful after meals in water. 



This solution is a very elegant stomachic 
tonic, which can be used in cases of general 
debility with failure of appetite and diges- 
tion occurring during convalescence, and at 
other times. 

When there is a tendency to diarrhoea, 
and no hepatic stimulation is required, 
hydrochloric acid may be substituted for 
nitrohydrochloric ; when there is a distinct 
tendency to diarrhoea, the following modifi- 
cation will often be found very useful : 

U Acidi sulphurici diluti, f^ii; 
Syr. zingiberis, f£i ; 
Strychninae sulph., gr. i. 
Misce et adde 

Tr. gentianae comp., f^ii; 
Tr. cinnamomi, f^iii. 
S. — Dessertspoonful after meals in water. 

No. 24. 

B Glycerini, 

Olei ricini, aa f^i ; 

Olei caryophylli, gtt. iv. 
Misce. 

S. — Shake thoroughly. Tablespoonful contains 
dessertspoonful of castor oil. 

If this mixture, after it is shaken to 
thorough homogeneity, be put into an ice- 
cold spoon or ice-cold water, it will congeal 
into a very thick mass which can be swal- 
lowed without disgust. 

No. 25. 

Elaterini, gr. ss ; 
Ext. belladonna?, gr. i; 
Olei caryophylli, gtt. x. 
Misce et fiant pilula? vi. 
S. — One every four to six hours until purga- 
tion occurs. 

No. 26. 

R Acidi hydrocyanici dil., gtt. xxiv ; 
Cocainao hydrochloratis, gr. iv ; 
Elixir, aromatici, f^iss. 
S. — Teaspoonful, repeated in forty minutes if 
needed. 

No. 27. 

U Strychninae sulph., gr. i ; 

Ext. quassia), gr. xxiv ; 

Oleoresinai capsici, gr. iv ; 

Olei caryophylli, gtt. xxiv. 
Misce et fiat massa in capsulas xxiv dividenda. 
S. — Ono directly after meals. 

No. 28. 

]£ Strontii salicylatis, ,^ii ; 

Strychnina) sulph., gr. i ; 

Naphtoli, gr. xxiv ; 

Acidi oarbolioi, gr. xviii. 
Misco et fiat massa in capsulas xxiv dividenda. 
S. — One directly after meals. 



CHARTS OF TEMPERATURE. 
Chart I. 



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106° 
105° 
104° 
103° 
102° 
101° 
100° 
99° 
98° 
97° 
96° 
95° 



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Scarlet Fever. (Boston City Hospital, Department for Contagious Diseases.) 

Chart II. 



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Small-Pox. (Boston City Hospital, Department for Contagious Diseases. | 

1067 




1068 



Chart VI. 



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Typhus Fever. (Murchison.) 
Chart YII. 



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Diphtheria, without antitoxin. (Boston City Hospital.) 
Chart VIII. 



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Diphtheria, with antitoxin. (Boston City Hospital.) 
10G9 



Chart IX. 



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Pneumonia, pseudo-crisis on the fifth day. (Massachusetts General Hospital.) 



Chart X. 



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DAYS OF 
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107° 
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Yellow Fever. (Bemiss.) 



1070 



Chart XI. 



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Malaria, Tertian Fever during convalescence from ovariotomy. (Massachusetts General 

Hospital.) 



Chart XII. 




Malaria, Double Tertian Infection. (Thayer and Hewetson.) 



1071 



INDEX. 



A. 

Abdominal aorta, aneurism of, 
696. 

dropsy, 967. 
Abscess, iliac, 876. 

of brain, 510. ( Vide Suppu- 
rative Encephalitis.) 

of kidney, 1040. 

of liver, 918. 

of spleen, 30. 

paranephritic, 1051. 

perinephritic, 1051. 

pulmonary, 766. 

retropharyngeal, 799. 

spinal, 547. 

subphrenic, 914. 
Abulia, 383. 
Acarus scabiei, 346. 
Acetonuria, 1012. 
Achromatopsia in hysteria, 409. 
Aconite, poisoning by, 358. 
Acoria, 849. 
Acromegaly, 626. 
Acro-paraesthesia, 623. 
Actinomyces, 231. 
Actinomycosis, 231. 
Acute articular rheumatism, 61. 

ataxia, 554. 

bronchitis, 712. 

infectious jaundice, 151. 

polymyositis, 44. 

tuberculosis, 244. 
Addison's disease, 41. 
Adenie, 16. 

Adenitis, tubercular, 281. 
Adijiosuria, 1000. 
Adrenal glands, diseases of, 41. 
Aerophagy, 850. 
iEstivo-autumrial fever, 207. 
African hypnosis, 463. 

sleeping disease, 463. 
Ageusia, 477. 
Aglyphia, 484. 
Agraphia, 484. 

literal, 485. 

musical, 484. 

verbal, 485. 
Ague and fever, 201. 
Albuminimeter, 1003. 
Albuminuria, 1001. 

cystic, 1003. 

febrile, 1004. 

functional, 1003. 

infectious, 1004. 

in le?d poisoning, 365. 
tests for, 1002. 



Albuminuria, intermittent, 
1003. 

neurotic, 1004. 

of adolescence, 1003. 

pathological, 1003. 

physiological, 1003. 

transitory, 1003. 
Albumosuria, 1001, 1005. 
Alcohol, acute poisoning by, 
351. 

chronic poisoning by, 368. 
Alcoholic insanity, 373. 
Alcoholism, 368. 
Alexia, 484. 
Algesia, 381. 

Alimentary canal, tuberculosis 

of, 265. 
Alkaptonuria, 999. 
Allocheiria, 579. 
Alopecia, syphilitic, 308. 
Amaurosis, 479. 
Amblyopia, 479. 
Amentia, 383. 
Amimia, ataxic, 484. 

sensory, 485. 
Amnesia, periodic, 467. 
Amoeba coli, 321. 

dysenterise, 321. 
Amusia, ataxic, 484. 

sensory, 484. 
Amyloid liver, 928. 
Amyotrophic lateral sclerosis, 

588. 
Anaemia, 2. 

cerebral, 492. 

essential, 9. 

idiopathic, 9. 

lymphatic, 16. 

of spinal cord, 545. 

pernicious, 9. 
progressive, 9. 

secondary, 3. 

simple, 2. 

spinal, 409, 545. 

splenic, 16. 

tropical, 3. 
Anaesthesia, 382. 

psychical, 391. 
Analgesia, 712. 
Anarthria, 484. 
Anatomist's tubercle, 250. 
Anohylostomum duodenale, 9. 
Aneurism, 691. 

arterio-venous, 691. 

by anastomosis, 691. 

cirsoid, 692. 

dissecting, 691. 

68 



Aneurism, false, 691. 
morbid anatomy, 692. 
nodular periarteritis in, 692. 
of abdominal aorta, 696. 
of aorta, 693. 
diagnosis, 693. 
physical examination in, 

694. 
prognosis, 696. 
treatment, 697. 
of heart, 648. 
serpentine, 692. 
symptoms, 692. 
tracheal tugging in, 695. 
treatment, 697. 
true, 691. 
varicose, 691. 
Aneurisms, cerebral, 497. 
Angina, 797. 
Ludovici, 187. 
pectoris, 682. 
diagnosis, 683. 
prognosis, 683. 
treatment, 684. 
vaso-motor, 682. 
Angioneurotic oedema, 622. 
Animal parasites, 321. 
Ankylostoma duodenale, 339. 
Ankylostomiasis, 339. 
Anorexia, 849. 
Anterior lobe, tumors of, 525. 
Antero-lateral sclerosis, 585. 
Anthracosis of lung, 756. 
Anthrax, 235. 

diagnosis, 236. 
prognosis, 236. 
treatment, 237. 
bacillus of, 235. 
internal, 236. 
malignant, 236. 
oedema, 236. 
Antimonial poisoning, 360, 368. 
Antiphtbisin, 241. 
Antitoxin of tetanus. 200. 

treatment of diphtheria, 177. 
Anuria, 1015. 

in hysteria, 110. 
Aorta, aneurism of, 093. 
Aortic insufficiency, 665. 

stenosis, 666. 
Aphasia, isi. 
ataxic, 484. 

cortical localization of, 486. 
motor, 484. 
sensory, 484. 
subcortical, 487. 
transcortical, 487. 

1073 



1074 



INDEX. 



Appendicitis, 876. 
abscess in, 878, 882. 

diagnosis, 883. 

etiology, 876. 

induration in, 880. 

morbid anatomy, 877. 

mortality of, 884. 

perforation in, 878. 

peritonitis in, 878, 882. 

prognosis, 884. 

surgical treatment, 889. 

symptoms, 879. 

termination of, 881. 

treatment, 887. 
chronic, 885. 
recurrent, 885. 
relapsing, 885. 
Apoplexy, 498 (note). 

serous, 493. 
Argyll-Robertson pupil, 478, 
580. 

Arithromania, 386. 
Arsenical poisoning, 360, 367. 
Apraxia, 487. 
Arachnitis, 489. 
Arhythmia, 681. 
Arteries, alterations of, in ne- 
phritis, 1018. 

atheromatous degeneration 
of, 686. 

diseases of, 686. 

syphilis of, 311. 
Arterio-capillary fibrosis, 1019. 
Arterio-sclerosis, 686. 

diagnosis, 690. 

morbid anatomy, 687. 

prognosis, 690. 

pseudo-cartilaginous plates 
in, 687. 

treatment, 690. 
Arthritis deformans, 71. 

rheumatic, chronic, 70. 

rheumatoid, 71. 

uratica, 76. 

urica, 76. 
Arthropodes, diseases due to, 

345. 

Articular rheumatism, acute, 
61. 

chronic, 70. 
Artificial feeding of infants, 869. 

respiration, 354. 
Ascariosis, 337. 
Ascaris lumbricoides, 337. 
Ascending paralysis, 548. 
Ascites, 967. ( Vide Hydroper- 
itoneum.) 

adipose, 968, 987. 

chylous, 968. 
Asiatic cholera, 219. 
Asphyxia, local, 620. 
Astasia abasia, 415. 
Asthma, 725. 

bronchial, 725. 

cardiac, 660, 725. 

diagnosis, 727. 

dyspeptic, 726. 

nervous, 726. 

paroxysms, treatment of, 
728. 

prognosis, 727. 

renal, 725. 



Asthma, sputum in, 726. 

symptoms, 726. 

thymic, 40, 725. 

thyroid, 725. 

treatment, 727. 

ursemic, 1016. 

uterine, 726. 
Ataxia, acute, 554. 

Friedreich's, 589. 

hysterical, 415. 

locomotor, 575. 
Ataxic aphasia, 484. 

paraplegia, 588. 
Atelectasis, 736. 

acquired, 736. 

congenital, 736. 

foetal, 736. 
Atheroma of arteries, 686. 
Athetosis, 380, 483. 

double, 483. 
Atrophic myopathy, 48. 
Atrophy, muscular neuritic, 

615. 

Atropine, poisoning by, 355. 
Aura epileptica, 420. 
Automatic movements, 378. 
Automatism, epileptic, 422. 
Azoturia, 93. 

B. 

Bacillus anthracis, 235. 

comma, 220. 

Klebs-Loeffler, 164. 

of anthrax, 235. 

of cholera, 220. 

of diphtheria, 164, 170. 

of erysipelas, 185. 

of leprosy, 301. 

of pneumonia, 741. 

of syphilis, 304. 

of tetanus, 194. 

of typhoid fever, 119, 135. 

of tuberculosis, 239, 241. 
staining of, 256. 

of whooping-cough, 179. 

tussis convulsive©, 179. 
Bacteria in acute endocarditis, 

651. 

Balantidium coli, 322. 
Bantingism, 59. 
Barlow's disease, 55. 
Basedow's disease, 33. 
Bedbug, 348. 
Beef tape-worm, 324. 
Bell's disease, 513. 

palsy, 611. 
Beri-beri, 609. 
Biceps jerk, 379. 
Big-jaw in cattle, 231. 
Bile-ducts, diseases of, 931. 
Biliary tract, tumors of, 947. 
Bilious fever, 207. 

rerrfittent fever, 207. 

typhoid fever, 151. 
Bilirubin in jaundice, 933. 
Black measles, 104. 

small-pox, 113. 
Bladder, diseases of, 1057. 

inflammation of, 1058. 

irrigation of, 1062. 

irritable, 1058. 



Bladder, neuralgia of, 1058. 

tuberculosis of, 283. 
Blepharoclonus, 431. 
Blepharospasm, 431. 
Blood, examination of, in mal- 
aria, 209. 
Blood-flukes, 335. 
Blood-vessels, alterations of, in 
nephritis, 1018. 
tuberculosis of, 283. 
Bone typhoid, 193. 
Bones, tuberculosis of, 285. 
Bothriocephalus cordatus, 324. 
cristatus, 324. 
latus, 324. 
liguloides, 324. 
Brach's symptom, 579. 
Bradycardia, 680. 
Brain, diseases of, 509. 
of membranes of, 488. 
dropsy of, 246. 
motor centres of, 473. 
softening of, 518. 
tubercle of, 242. 
tuberculosis of, 284. 
tumors of, 524. 
Brenzkatechinuria, 999. 
Bright's disease, 1022. 
acute, 1023. 

diagnosis, 1025. 
morbid anatomy, 1023. 
prognosis, 1025. 
symptoms, 1023. 
treatment, 1025. 
urine in, 1024. 
second stage, 1028. 
diagnosis, 1030. 
prognosis, 1031. 
symptoms, 1029. 
treatment, 1031. 
third stage, 1033. 
diagnosis, 1036. 
morbid anatomy, 1033* 
prognosis, 1037. 
symptoms, 1034. 
treatment, 1037. 
British plague, 118. 
Bronchi, diseases of, 712. 
Bronchial asthma, 725. 
catarrh, acute, 712. 

chronic, 717. 
obstruction, 723. 
Bronchiectasis, 721. 
morbid anatomy, 722. 
symptoms, 722. 
treatment, 723. 
Bronchitis, acute, 712. 
'diagnosis, 714. 
symptoms, 713. 
treatment, 714. 
of first stage, 715. 
of second stage, 716. 
capillary, 713. 
cheesy, 252. 
chronic, 717. 
symptoms, 718. 
treatment, 719. 
dry, 718. 

epidemic capillary, 104. 
membranous, 720. 
putrid, 718. 
Bronchocele, 31. 



INDEX. 



1075 



Broncho-pneumonia, 759. 
diagnosis, 761. 
prognosis, 762. 
symptoms, 760. 
treatment, 762. 
lobular, 760. 
nodular, 759. 
Bronchorrhoea, 718. 

serous, 718. 
Brow ague, 206, 456. 
Bulbar palsy, 537. 
Bulimia, 850. 
Bursitis, omental, 951. 

C. 

Cachexia strumipriva, 38. 
Caisson disease, 449. 
Calabar bean, poisoning by, 357. 
Calculi, biliary, 939. 

pancreatic, 955. 

renal, 1053. 
Camp-fever, 145. 
Cancer of gall-bladder, 948. 

of gall- duct, 948. 

of intestines, 900. 

of liver, 928. 

of lung, 767. 

of oesophagus, 812. 

of pancreas, 960. 

of peritoneum, 986. 

of stomach, 843. 
Cancrum oris, 792. 
Cantharides, poisoning by, 361. 
Carbolic acid, poisoning by, 352. 

antidote, 353. 
Cardiac asthma, 660. 

collapse, 330. 

dilatation, 670, 674. 

dropsy, 662. 

epilepsy, 423. 

hypertrophy, 669. 

murmur of aortic valve, 665, 
666. 

of mitral valve, 664, 665. 

of pulmonary valve, 668. 

of tricuspid valve, 667. 
neuroses, 678. 
palpitation, 676. 
Casts, renal, blood, 1014. 

epithelial, 1014. 

fatty, 1014. 

granular, 1014. 

hyaline, 1013. 

mucous, 1013. 

waxy, 1014. 
Catarrh, autumnal, 704. 
bronchial, acute, 712. 

chronic, 717. 
dry, 718. 

gastric, acute, 827. 
chronic, 831. 

nasal, acute, 701. 
chronic, 702. 
Cephalodynia, 74. 
Cercomonas coli hominis, 322. 

intestinalis, 322. 
Cerebellar localization, 487. 
Cerebellum, tumors of, 526. 
Cerebral anasmia, 492. 

aneurism, 497. 

convulsions, 378. 



Cerebral embolism, 494. 
hemorrhage, 498. 
after-history of, 503. 
convulsions in, 501. 
diagnosis, 504. 
paralysis in, 502. 
secondary degeneration in, 
500. 

symptomatology, 500. 
temperature in, 501. 
treatment, 506. 
trephining in, 505. 
hyperaemia, 493. 
localization, 471, 481. 
oedema, 493. 
palsy of children, 508. 
rheumatism, 65. 
sinus, thrombosis of, 497. 
syphilis, 528. 
tetanus, 198. 
thrombosis, 493. 
Cerebro-spinal meningitis, 152. 
anomalous forms, 155. 
chronic, 155. 
diagnosis, 156. 
malignant form, 155. 
morbid anatomy, 153. 
ordinary type, 154. 
prognosis, 156. 
symptomatology, 153. 
treatment, 156. 
sclerosis, multiple, 522. 
Chalicosis of lungs, 756. 
Chancre, hard, 306. 
Character, 388. 
Charcot-crystals, 13. 
Charcot-Marie type of muscu- 
lar atrophy, 616. 
Charcot, sensory crossway of, 
482. 

Charts of temperature, 1067- 
1071. 

Cheesy bronchitis, 252. 

pneumonia, 252. 
Cheyne-Stokes breathing, 660. 
Chigoe, 348. 

Chloral, poisoning by, 351. 
Chloroform, poisoning by, 352. 
Chloroma, 15. 
Chlorosis, 4. 

diagnosis, 6. 

prognosis, 7. 

treatment, 7. 
Choked disk, 477. 
Cholangitis, 935. 
Cholecystenterostomy, 947. 
Cholecystitis, 935. 
Cholecystotomy, 947. 
Choledochitis, 936. 

catarrhal, 936. 
Choledochotomy, 947. 
Cholelithiasis, 939. 

biliary colic in, 941. 

composition of stone, 940. 

diagnosis, 943. 

impaction of stone, 943. 

jaundice in, 942. 
' morbid anatomy, 940. 

prognosis, 944. 

surgical treatment, 946. 

symptoms, 941. 

treatment, 945. 



Cholera, Asiatic, 219. 
algid period, 222. 
comma bacillus in, 220. 
diagnosis, 223. 
enteroclysis in, 225. 
intravenous injection in, 
225. 

morbid anatomy, 221. 

prognosis, 223. 

prophylaxis, 223. 

stools in, 221. 

symptomatology, 221. 

treatment, 223. 
infantum, 226, 861. 

treatment, 863. 
morbus, 225. 
nostras, 225. 
sicca, 223. 
Cholerine, 222. 

Chorea, 432. ( Vide St. Vitus's 
dance.) 

automatic, 439. 

convulsive, 438. 

electric, 438. 

general, 380. 

Germanorum, 439. 

habit, 438. 

hereditary, 440. 

Huntingdon's, 440. 

hysterical, 438. 

local, 380. 

minor, 432. 

of childhood, 432. 

of pregnancy, 437. 

organic, 438. 

post-hemiplegic, 483. 

pre-hemiplegic, 483. 

reflex, 437. 

rhythmical, 380. 

senile, 438. 
Choreic movements, 380. 

tic, 438. 
Chylothorax, 774. 
Chyluria, 1000. 
Cimex lectularius, 348. 
Circular insanity, 399. 
Cirrhosis of kidney, 1033. 

of liver, 923. 

of lung, 264, 756. 
Citric acid, poisoning by, 360. 
Clonus, 379. 

Cocaine, poisoning by, 355, 356. 
Cocainism, 376. 
Coccidium oviforme, 321. 
Cold in the head, 701. 
Colic from lead, 333. 

mucous, 870. 
Colica pictonum, 362. 
Colitis, pseudo-membranous, 

870. 

Colles's law in syphilis, 304. 
Coloptosis, 855. 
Coma, 460. 

in cerebral syphilis, 534. 
Combined sclerosis, 588. 
Comma bacillus in cholera, 220. 
Compression myelitis, 55S. 
Confusion,! i insanity, 395. 
Congenita] myotonia, 
Congestive malarial fever, 208. 
Conium, poisoning by, 358. 
Consciousness, double, 467. 



1076 



INDEX. 



Constipation, 903. 

diagnosis, 905. 

symptoms, 904. 

treatment, 905. 
Constitutional diseases, 41. 
Consumption, pulmonary, 251. 
Contractions, paradoxical, 379. 
Convulsions, 378, 430. 

cerebral, 378. 

epileptiform, 378. 

hysterical, 378. 

in epilepsy, 419. 

spinal, 378. 

tetanic, 378. 
Convulsive tic, 431. 
Coordination, disturbances of, 
380. 

station test for, 3 SO. 
Coprolalia, 440. 

Corpora quadrigeurina, tumors 

of, 526. 
Corrigan's pulse, 666. 
Corrosive sublimate, poisoning 

by, 300. 
Coryza, 703. 
Costiveness, 903. 
Cough, treatment of, 716. 
Cow-pox, 116. 
Cramp, writer's, 455. 
Craniotabes, 521. 

in rickets, 52. 
Cranium, tumors within, 524. 
Cretinism, 37. 
Croup, false, 707. 

membranous, 707. 

pseudo-membranous, 707. 
Crus, tumors of, 526. 
Cryptogenic septicaemia, 190. 
Cupric sulphate, poisoning by, 

361. 

Cycloplegia, 595. 
Cyclothvmia, 399. 
Cysticercus cellulosae, 323, 327. 

disease, 354. 
Cystinuria, 1009. 
Cystitis, 1058. 

catheterization in, 1061. 

diagnosis. 1060. 

from spinal paralysis, 1062. 

irrigation in, 1062. 

local causes of, 1059. 

morbid anatomy, 1059. 

prognosis, 1061. 

symptoms, 1059. 

treatment, 1061. 

urine in, 1059. 
Cvsts of pancreas, 957. 

renal, 1042. 

D. 

Dactylitis syphilitica, 310. 
Debauch, 369. 
Decubitus acutus, 553. 
Delirifacients, poisoning by, 
355. 

Delirium grave, 513. 
in typhoid fever, 125. 
tremens, 369. 

complications, 370. 
congestion of the lungs in, 
372. 



Delirium tremens, diagnosis, 
370. 

hallucinations in, 369. 
prognosis, 371. 
treatment, 371. 
Delusions, 384. 
expansive, 3S5. 
hypochondriacal, 385. 
insane, 385. 
of persecution. 385. 
systematized, 385. 
Dementia, 383. 
paralytica, 516. 
primary, curable, 395. 
terminal, 397. 
Demodex folliculorum, 346. 
Dengue, 161. 
Diabetes insipidus, 92. 
mellitus, 85. 
coma in, S9. 
diagnosis, S9. 
diet in, 90. 
pancreas in, 86. 
prognosis, 90. 
symptoms, S7. 
treatment, 90. 
urine in, 88. 
Diaceticaciduria, 1012. 
Diarrhoea of infants, acute, 
860. 
feeding in, 865. 
treatment, 863. 
chronic, 868. 
treatment, 870. 
Diazo-reaction in typhoid fever, 
134. 

Dilatation of stomach, 823. 
diagnosis, 825. 
lavage in, 826. 
physical examination, 

825. 
prognosis, 825. 
symptoms, 824. 
treatment, 826. 
Diphtheria, 163. 

antitoxin treatment, 177. 
bacillus of, 164, 170 
complications, 169. 
croupous symptoms in, 169. 
diagnosis, 170. 

false membrane in, 166, 170, 
174. 

fibrinous inflammation in, 
166. 

local treatment, 173. 

Loeffler's solution in, 175. 

morbid anatomy, 165. 

mucous membranes, 165. 

paralysis following, 169. 

prognosis, 171. 

pseudo-membranous sore 
throat in, 165. 

putrid sore throat in, 166. 

symptomatology, 168. 

treatment, 172. 
antitoxin, 177. 
Diphtherite, 163. 
Diphtheroid, 171. 
Diplegia, facial, 612. 
Diplococcus pneumonia?, 742. 
Diplopia, 481. 

crossed, 481. 



Diplopia, homonymous, 481. 

monocular, 481. 

simple, 481. 
Disease, Addison's, 41. 

African sleeping, 463. 

Barlow's, 55. 

Basedow's, 33. 

Bell's, 513. 

Bright's, 1022. 

caisson, 449. 

cysticercus, 327. 

echinococcus, 329. 

English sweating, 118. 

foot-and-mouth, 237. 

Graves's, 33. 

Gilles de la Tourette's, 439. 

Hodgkin's, 16. 

hydatid, 329. 

Madura foot, 232. 

Meniere's, 418. 

Morvan's, 574. 

Raynaud's, 619. 

Schoenlein's, 25. 

Voltolini's, 418. 

Weil's, 151. 

Werlhof's, 26. 
Diseases, constitutional, 44. 

due to animal parasites, 
348. 

infectious, 95. 

locomotor, 44. 

malarial, 204. 

of adrenal glands, 44, 

of bile-duets, 931. 

of brain, 509. 

of bronchi, 712. 

of gall-bladder, 931. 

of heart, 637. 

of intestines, 855. 

of larynx, 707. 

of liver, 909. 

of lungs, 730. 

of mediastinum, 787. 

of medulla oblongata, 536. 

of membranes of brain, 488. 

of nerve-trunks, 594. 

of nose, 700. 

of pericardium, 628. 

of pleura, 770. 

of spleen, 28. 

of thymus gland, 40. 

of thyroid gland, 31. 

of trachea, 712. 

trophic, 619. 

vaso-motor, 619. 
Disseminated sclerosis, 521. 

tuberculosis, 244. 
Distoma conjunctum, 335. 

crassum. 335. 

haematobium, 335. 

hepaticum, 336. 

heterophyes, 335. 

lanceolatum, 335. 

ophthalmobium, 335. 

pulmonale, 336. 

sinense, 335. 
Distomiasis, 336. 
Dochmiasis, 339. 
Double athetosis, 4S3. 
Doubt, delirium of, 387. 
Dracontiasis, 341. 
Dropsy, abdominal, 967. 



INDEX. 



1077 



Dropsy, cardiac, 662. 

of gall-bladder, 936. 

renal, 1018. 

treatment, 1032. 
Duchenne's form of atrophic 

myopathy, 48. 
Ductless glands, tuberculosis of, 

281. 

Dysesthesia, 552. 
Dysentery, 212. 

abscess of liver in, 214. 

amoeba in, 212. 

catarrhal inflammation in, j 

213. 
diagnosis, 216. 
diphtheritic inflammation 

in, 214. 
follicular inflammation in, 

213. 

morbid anatomy, 213. 

prognosis, 216. 

stools in, 215. 

symptoms, 215. 

treatment, 217. 
amoebic, 214. 
chronic, 214, 216. 
tropical, 212. 
Dyspepsia, acute, 827. 
chronic, 831. 
nervous, 852. 
treatment, 853. 
Dysthesia, psychical, 391. 

E. 

Echinococci of heart, 332. 
of kidney, 333. 
of liver, 332. 
of lungs, 333. 
of peritoneum, 334. 
of pleura, 332. 
Echinococcus disease, 329. 
cysts in, 330. 
diagnosis, 335. 
localization of, 332. 
prognosis, 335. 
symptoms, 331. 
treatment, 335. 
Echolalia, 440. 

Ehrlich's test for typhoid fever, 
134. 

Elbow-jerk, 379. 
Electrical sensibility, 381. 
Elephantiasis, 341. 

Grascorum, 301. 
Embolism, cerebral, 494. 

diagnosis, 496. 

prognosis, 497. 

treatment, 497. 
in endocarditis, 653. 
of spleen, 30. 
Emotion, 388. 
Emphysema, 738. 

alveolar, 738. 

collateral, 739. 

complementary, 739. 

essential, 738. 

Gerhardt's treatment of, 
740. 

interstitial, 733. 

senile, 739. 

symptoms, 739. 



Emphysema, treatment, 740. 
vesicular, 738. 
vicarious, 739. 
Empyema, 777. 
necessitatis, 778. 
pulsating, 781. 
Encephalitis, acute hemorrha- 
gic, 509. 
hypertrophic, 510. 
peripheral, 513. 
sclerotic, 510. 
suppurative, 510. 
Encephalopathia saturnina, 363. 
Endarteritis chronica nodosa 

sive deformans, 686. 
Endarteritis, syphilitic, 311. 
Endocarditis, acute, 651. 
bacteria in, 652. * 
cause of, 655. 
diagnosis, 656. 
embolism in, 653. 
malignant, 654. 
morbid anatomy, 652. 
murmur in, 654. 
prognosis, 656. 
pysemic, 655. 
septic, 654. 
symptoms, 653. 
treatment, 656. 
types of malignant, 654. 
valvular aneurism in, 653. 
chronic, 657. 

brown induration of lungs 

in, 661. 
calcification in, 658. 
Cheyne-Stokes breathing 

in, 660. 
dropsy in, 662. 
dyspnoea in, 660. 
embolism in, 662. 
fibrous, 658. 
insufficiency in, 659. 
kidneys in, 662. 
nutmeg liver in, 661. 
parietal form of, 657. 
prognosis, 663. 
stenosis in, 659. 
symptoms, 659. 
treatment, 668, 676. 
ulcerative, 658. 
urine in, 662. 
valvular forms of, 657. 
venous pulsation in, 661. 
English sweating disease, 118. 
Enteritis, 857. 

acute catarrhal, 859. 
diagnosis, 861. 
feeding in, 862. 
of infants, 860. 
feeding in, 865. 
treatment, 863. 
stools in, 859. 
symptoms, 859. 
treatment, 861, 863. 
chronic, 866. 
catarrhal, 866. 
symptoms, 866. 
treatment, S67. 
diphtheritic, 875. 
follicular, 859, 873. 
gangrenous, S75. 
phlegmonous, 875. 



Enteritis, pseudo-membranous, 
870. 

enemata in, 872. 
treatment, 871. 

tubercular, 267. 

ulcerative, 872. 
symptoms, 873. 
treatment, 874. 

varieties of, 858. 
Enteroliths, 894. 
Enteroptosis, 855. 
Enuresis, 1057. 

nocturnal, 1057. 
Epidemic capillary bronchitis, 
104. 

parotitis, 183. 
Epilepsia procursiva, 421. 
Epilepsy, 418. 

anomalous forms of, 421. 

aura in, 420. 

cardiac, 423. 

convulsions in, 419. 

diagnosis, 423. 

idiopathic, 418. 

Jacksonian, 525. 

morbid anatomy, 419. 

nocturnal, 421. 

procursive, 421. 

prognosis, 424. 

reflex, 423. 

senile, 680. 

spinal, 586. 

surgical treatment, 428. 

symptomatology, 419. 

theory of cause, 419. 

toxsemic, 423. 

treatment, 425. 
Epileptic automatism, 422. 

mania, 422. 

status, 422. 
Epileptiform convulsions, 378. 
Epistaxis, 700. 

Erb's farm of atrophic myopa- 
thy, 48. 

Erotomania, 386. 

Eructation, nervous, 850. 

Erysipelas, 185. 
diagnosis, 188. 
migrans, 187. 

of mucous membranes, 187. 
phlegmonous, 187. 
pneumonia, 188. 
prognosis, 188. 
symptomatology, 186. 
treatment, 188. 
Essential anamiia, 9. 
Eustrongylus gigas, 339. 
Exophthalmic goitre, 33. 
diagnosis, 35. 
electricity in, 36. 
prognosis, 35. 
treatment. 36. 
Expansive delusion, 385. 

F. 

Facial diplegia, 612. 

nerve, neuritis of, 611. 
paralysis of, 596. 

spasm, 431. 
Facio-scapulo- humeral typo of 

atrophic myopathy, 48. 



1078 



INDEX. 



Faeces, impacted, 907. 
Fallopian tubes, tuberculosis of, 

274. 
Farcy, 237. 

buds, 237. 

sores, 237. 
Fehling's test for sugar in urine, 

1011. 

Fermentation test for sugar in 

urine, 1011. 
Fever, gestivo-autumnal, 207. 

ardent, continued, 451. 

bilious, 207. 
remittent, 207. 

break-bone, 161. 

camp, 145. 

charts, 1067-1071. 

congestive malarial, 208. 

hay, 704. 

hectic, in phthisis, 261, 299. 

infantile remittent, 131. 

intermittent, 201. 

malarial, 201. 
congestive, 208. 

malignant, 208. 

miliary, 118. 

pernicious, 208. 

pneumo-typhoid, 130. 

prison, 145. 

relapsing, 149. 

remittent, 207. 
bilious, 207. 

rheumatic, 61. 

scarlet, 95. 

ship, 145. 

spotted, 152. 

thermic, 450. 

typhoid, 119. 

typho-malarial, 132. 

typhus, 145. 

walking typhoid, 130. 

yellow, 226. 
Fibrinuria, 1006. 
Fibroid phthisis, 264. 
Fibrous pneumonia, 264. 
Filaria bronchialis, 342. 

labialis, 342. 

lentis, 342. 

Loa, 342. 

medinensis, 340. 

sanguinis hominis, 9, 341. 
Fish tape-worm, 324. 
Fleas, 348. 
Flies, house-, 348. 
Flukes, 335. 

Foetal rickets, 50 (note). 

syphilis, 314. 
Foot-and-mouth disease, 237. 
Formes frustes, 33. 
Formulary, 1063. 
Friedreich's ataxia, 589. 

G. 

Galacturia, 1000. 
Gall-bladder, cancer of, 948. 

diseases of, 931. 

dropsy of, 936. 

empyema of, 936. 

inflammation of, 935. 
Gall-ducts, cancer of, 948. 

inflammation of, 935. 



Gall-ducts, inflammation of, 
diagnosis, 937. 
morbid anatomy, 936. 
prognosis, 938. 
symptoms, 937. 
treatment, 938. 
suppurative inflammation of, 
936. 
treatment, 939. 
Gall-stones, 939. ( Vide Choleli- 
thiasis.) 
composition of, 940. 
impaction of, 943. 
incarceration of, 942. 
Gangrene, diabetic, 690. 
local, 620. 
pulmonary, 764. 
diagnosis, 765. 
prognosis, 766. 
symptoms, 765. 
treatment, 766. 
senile, 690. 
symmetrical, 619. 
Gastralgia, acute, 598, 850. 

treatment, 842. 
Gastralgokenosis, 850. 
Gastrectasia, 823. 
Gastric catarrh, acute, 827. 
chronic, 831. 
neuroses, 849. 
Gastritis, 827. 
acute acid, 833. 
catarrhal, 827. 
diagnosis, 829. 
prognosis, 829. 
pyrosis in, 828. 
symptoms, 828. 
water-brash in, 828. 
atrophic, 832. 
chronic catarrhal, 831. 
diagnosis, 833. 
lavage in, 835. 
prognosis, 833. 
symptoms, 832. 
treatment, 835. 
hypertrophic, 831. 
phlegmonous, 829. 
pseudo-membranous, 829. 
toxic, 830. 
Gastro-adenitis, parenchyma- 
tous, 828. 
Gastrodiaphany, 829. 
Gastrodynia, 850. • 
Gastroptosis in chlorosis, 5. 
Gastroxyrosis, 852. 
Gelsemium, poisoning by, 358. 
Geographic tongue, 794. 
Gerhardt's treatment of emphy- 
sema, 740. 
German measles, 107. 
Giant urticaria, 622. 
Gilles de la Tourette's disease, 

439. 
Glanders, 237. 
chronic, 238. 
diagnosis, 238. 
prognosis, 239. 
treatment, 239. 
Globulinuria, 1001, 1004. 
Globus hystericus, 407. 
Glossitis, 793. 

parenchymatous, 794. 



Glosso-labial paralysis, 537. 
Glycosuria, 85, 1009. {Vide 

Diabetes mellitus.) 
Gmelin's test for bilirubin, 933. 
Goitre, 31. 

exophthalmic, 33. 
Gonorrhceal rheumatism, 68. 
Gout, 76. 

alcohol in, 77. 

articular, 78. 

baths in, 83. 

chronic, 78. 

diagnosis, 79. 

diet in, 83. 

heredity in, 76. 

kidneys in, 77. 

local treatment of, 82. 

metastatic, 79. 

morbid anatomy, 77. 

prognosis, 80. 

retrocedent, 79. 

retrograde, 79. 

rheumatic, 71. 

symptoms, 78. 

tophi in, 77. 

treatment, 81. 

uric acid in, 76, 78, 80. 

visceral, 78. 
Graves's disease, 33. 
Grease, 39. 
Green sickness, 4. 
Grippe, 158. 
Guinea-worm, 340. 

H. 

Haematemesis, 839. 
Haematidrosis, 410. 
Haematocele, 962. 
Hasmatochyluria, 341. 
Haematoma of dura mater, 488. 
Haematomyelia, 543. 
Haematomyelitis, 553. 
Haematorrhachis, 543. 
Haematozoa, 321. 

of malaria, 203, 321. 
Haematuria, 994. 

source of, 995. 
Hasmoglobinaemia, 27. 
Haemoglobinuria, 996. 

paroxysmal, 997. 
Haemopericardium, 628. 
Hagrnoperitoneum, 962. 
Haemophilia, 20. 
Haamoptysis, 732. 

in phthisis, 259. 
Haemosalpinx, 963. 
Haemothorax, 774. 
Hallucinations, 384. 
Harvest-mite, 346. 
Hay fever, 704. 
Headache, 456. 

caffeinic, 457. 

gastric, 457. 

gouty, 457. 

lithagmic, 457. 

nervous, 457. 

sympathetic, 457. 

toxaemic, 456. 
Hearing, centre for, 476. 
Heart, alterations of, in ne- 
phritis, 1018. 



INDEX. 



1079 



Heart, aneurism of, 648. 

aplasia of, 638. 

atrophy of, 638. 

dilatation of, 641, 670, 674. 

diseases of, 637. 

echinococci of, 332. 

endocarditis of, 657. 
prognosis, 663. 
symptoms, 659. 
treatment, 668. 

fatty degeneration of, 643. 

fatty infiltration of, 642. 

gummata in, 311. 

hypertrophy of, 639, 669. 

hypoplasia of, 638. 

irritable, 678. 

malformation of, 637. 

murmurs, 664 et seq. 

neuralgia of, 682. 

palpitation of, 676, 678. 

rupture of, 649. 

syphilitic disease of, 311. 

thrombosis of, 648. 

tuberculosis of, 283. 

tumors of, 650. 

valvular lesions of, 675. 
treatment, 668, 673, 676. 
Heat exhaustion, 450. 

test in albuminuria, 1002. 
Hebephrenia, 398. 
Heberden's nodules in gout, 77. 
Helminthiasis, 322. 
Hemeralopia, 933. 
Hemianopsia, heteronymous, 
479. 

homonymous, 479. 

lateral, 479. 
horizontal, 479. 
Hemiatrophy, facial, 625. 
Hemichorea, 380, 483. 
Hemiopia periodica, 459. 
Hemiplegia, 377. 
Hemitremors, 483. 
Hemorrhagic diathesis, 19. 
encephalitis, 509. 
rickets, 55. 
small-pox, 110, 113. 
Henoch's purpura, 26. 
Hepatitis, acute parenchyma- 
tous, 916. 
chronic interstitial, 923. 
fibrous, 923. 
ascites in, 925. 
diagnosis, 926. 
hemorrhage in, 924. 
morbid anatomy, 923. 
prognosis, 926. 
symptoms, 924. 
treatment, 926. 
varieties, 923. 
suppurative, 918. 
diagnosis, 921. 
enlargement in, 921. 
morbid anatomy, 919. 
prognosis, 922. 
symptoms, 920. 
treatment, 922. 
Hereditary chorea, 440. 
Heteronymous hemianopsia, 

479. 
Hiccough, 416. 
Hiccup, 416. 



Hirudo ceylonica, 336. 

vorax, 336. 
Hodgkin's disease, 16. 
Homonymous hemianopsia, 479. 

lateral hemianopsia, 479. 
Hydatid disease, 329.. 
Hydatids of heart, 359. 

of kidney, 359. 

of liver, 359. 

of lungs, 359. 

of peritoneum, 359. 
Hydrocephalus, 512. 

acute, 246. 

externus, 512 (note). 

internus, 512 (note). 

spurious, 493. 
Hydrochinonuria, 999. 
Hydrochloric acid in gastric 
juice, tests for, 820. 
poisoning by, 360. 
tests for, in cancer of 
stomach, 847. 
Hydromyelia, 572. 
Hydronephrosis, 1048. 

diagnosis, 1050. 

intermittent, 1050. 

morbid anatomy, 1049. 

operation in, 1051. 

prognosis, 1051. 

symptoms, 1049. 

treatment, 1051. 
Hydropericardium, 629. 
Hydroperitoneum, 967. 

cachectic, 967. 

diagnosis, 970. 

fluid of, 967, 971. 

mechanical, 967. 

morbid anatomy, 967. 

physical examination, 969. 

prognosis, 971. 

symptoms, 969. 

treatment, 972. 

vaginal examination, 970. 
Hydrophobia, 233. 

spurious, 407. 
Hydropneumothorax, 771. 
Hydrothionuria, 1013. 
Hyperesthesia, 382. 

psychical, 391. 
Hyperbulia, 382. 
Hypergeusia, 477. 
Hyperorexia, 849. 
Hypertrophic cirrhosis of liver, 

927. 

Hypochondriacal delusions, 
385. 

Hypomania, 394. 
Hysteria, 405. 

anuria in, 410. 

beast mimicry, 407. 

bloody sweat, 410. 

blue oedema in, 410. 

convulsions in, 407. 

diagnosis, 411. 

globus hystericus, 407. 

headache in, 458. 

mental symptoms, 406. 

opisthotonos in, 407. 

phantom tumor, 412. 

prognosis, 412. 

sight in, 409. 

treatment, 412. 



Hysterical anaesthesia, 409. 
ataxia, 415. 
breast, 412. 
chorea, 438. 
convulsions, 327, 378. 
paralysis, 408. 
somnolence, 408. 
trance, 408. 
vertigo, 417. 

I. 

Icterus, 931. 

febrile, 151. 
Iliac abscess, 876. 

phlegmon, 876. 
Illuminating gas, poisoning by, 

351. 
Illusion, 384. 
Imperative act, 386. 

conception, 385. 
Incoherence, 383. 
Indicanuria, 998. 
Infantile form of atrophic my- 
opathy, 48. 

osteomalacia, 57. 

remittent fever, 131. 

scurvy, 55. 

spastic paralysis, 508. 
Infectious diseases, 95. 
Influenza, 158. 

complications, 160. 

diagnosis, 160. 

duration, 159. 

prognosis, 160. 

treatment, 160. 
Infusoria, 322. 
Insane delusions, 385. 

general paralysis of, 510. 
Insanity, 389. 

alcoholic, 373. 

circular, 399. 

confusional, 395. 

hallucinatory, 395. 

menstrual, 399. 

periodical, 399. 

puerperal, 515. 

post-febrile, 395. 

stuporous, 395. 

surgical, 395. 
Insanities, complicating, 389 
(note). 

constitutional, 390. 

functional, 391. 

neuropathic, 391, 397. 

organic 389 (note). 

pure, 391. 

toxannic, 390. 
Insects, parasitic, 346. 
Insomnia, 461. 

Intellection, disturbances of, 
382. 

Intermittent fever, 201. ( Vide 

Malarial Diseases.) 
Intestinal tuberculosis, 265. 

diagnosis, 268. 

secondary, 267. 

symptoms, 267. 

treatment, 299. 

ulcers in, 266. 
Intestine, abnormal contents of, 
894. 



1080 



INDEX. 



Intestine, cancer of, 900. 
diagnosis, 902. 
symptoms, 901. 
prognosis, 903. 
treatment, 903. 
enteroliths in, 894. 
hemorrhage into, 855. 

in typhoid fever, 128. 
intussusception, 892. 
diagnosis, 896. 
laparotomy in, 900. 
prognosis, 898. 
treatment, 899. 
knots in, 893. 
obstruction of, 891. 
diagnosis, 896. 
prognosis, 898. 
symptoms, 895. 
treatment, 899. 
obstruction of, chronic, 896. 
perforation of, in typhoid 

fever, 122, 128, 144. 
strangulation of, 892. 
stricture of, 894. 
tuberculosis of, 265. 
tumors of, 894. 
twisting of, 893. 
ulcers of, amyloid, 873. 
catarrhal, 873. 
follicular, 873. 
stercoral, 873. 
Intra-cranial tumors, 524. 
Intra-peritoneal hemorrhage, 
962. 
diagnosis, 965. 
ectopic pregnancy, 963. 
morbid anatomy, 963. 
physical examination, 

964. 
prognosis, 966. 
symptoms, 963. 
treatment, 966. 
Iridoplegia, 595. 

reflex, 580. 
Itch insect, 346. 
Ixodes americanus, 346. 
ricinus, 346. 



J 

Jacksonian epilepsy, 525. 
Jaundice, 931. 

bilirubin in, 933. 
diagnosis, 934. 
morbid anatomy, 932. 
obstruction to flow of bile 

in, 932. 
prognosis, 935. 
skin in, 934. 
stools in, 934. 
symptoms, 932. 
treatment, 935. 
urine in, 933. 
vision in, 933. 
acute infectious, 151. 
catarrhal, 937. 
haematogenous, 931. 
Jiggers, 348. 

Joints, intermittent dropsy of, 
623. 

tuberculosis of, 285. 



Jumpers, 439. 

Juvenile form of atrophic my- 
opathy, 48. 

K. 

Keloid, 625. 

Kidney, abscess of, 1040. 

amyloid degeneration of, 

1038. 
anomalies of, 989. 
atrophy, granular, of, 1033. 
Bright's disease of, 1022. 
cirrhosis of, 1033. 
congestion of, 1019. 

passive, 1020. 
contracted, 1033. 
cyanotic induration of, 662. 
cystic dropsy of, 1042. 
cysts of, 1042. 
diseases of, 989. 
echinococci in, 332. 
embolism of, 1021. 
fatty, 1028. 
floating, 989. 

diagnosis, 992. 

prognosis, 992. 

symptoms, 990. 

treatment, 993. 

urine in, 991. 
fused, 989. 
gouty, 1033. 

granular atrophy of, 1033. 
induration of, 662. 
inflammation of, acute, 1022. 
large white, 1028. 
movable, 989. 
multilocular cystic, 1042. 
scrofulous, 270. 
small granular, 1033. 
surgical, 1040. 
thrombosis of, 1021. 
tuberculosis of, 270. 
tumors of, 1043. 
wandering, 989. 
Klebs-Loeffler bacillus, 164, 
170. 

Kleptomania, 386. 
Knee-jerk, 378. 

in cerebral tumors, 527. 
Kyphosis, 601. 

paralytic, 601. 



L. 

Lactosuria, 1010. 
Lamblia intestinalis, 322. 
Landouzy's form of atrophic 

myopathy, 48. 
Landry's paralysis, 548. 
Laryngeal phthisis, 263. 
Laryngismus stridulus, 429. 
Laryngitis, acute, 707. 
diagnosis, 708. 
prognosis, 708. 
treatment, 708. 

chronic, 709. 

syphilitic, 710. 
Larynx, diseases of, 706. 

oedema of, 71 0. 

phthisis of, 263. 

tumors of, 711. 



Latah, 439. 

Lateral curvature of spine, 
601. 

Lavage in chronic gastritis, 
835. 

in dilatation of stomach, 826. 
Lead colic, 333. 
paralysis, 334. 
poisoning by, 362. 
albuminuria in, 365. 
amblyopia in, 364. 
diagnosis, 366. 
treatment, 366. 
wrist-drop in, 363. 
Leeches, 336. 
Lepra, 301. 
Leprosy, 301. 
anaesthetic, 302. 
bacillus of, 301. 
diagnosis, 303. 
nodular, 303. 
prognosis, 303. 
treatment, 304. 
tubercular, 303. 
Leptomeningitis, 489, 546. 
Leptus irritans, 346. 
Leukaemia, 12. 
blood in, 14. 
diagnosis, 15. 
prognosis, 16. 
symptoms, 13. 
treatment, 16. 
Leukocytosis, 11. 
Leukoplakia, buccal, 794. 
Lieno-lymphatic leukaemia, 13. 
Lipaciduria, 1012. 
Lipaemia, 1001. 
Lipuria, 1000. 
Lithaemia, 80. 
Lithuria, 1006. 
Liver, abscess of, 918. 

acute yellow atrophy of, 916. 
diagnosis, 918. 
morbid anatomy, 917. 
prognosis, 918. 
symptoms, 917. 
treatment, 918. 
amyloid, 928. 
atrophy of, nutmeg, 912. 

red, 912. 
cancer of, 928. 
diagnosis, 931. 
morbid anatomy, 929. 
prognosis, 931. 
symptoms, 930. 
treatment, 931. 
urine in, 930. 
cirrhosis of, 923. 
atrophic, 924. 
hypertrophic, 927. 
congestion of, 911. 
diseases of, 909. 
echinococci of, 332. 
fatty infiltration of, 910. 
-fluke, 336. 

hypertrophic cirrhosis of, 927. 
malformation of, 909. 
malposition of, 909. 
nutmeg, 661. 
syphilitic disease of, 312. 
tuberculosis of, 268. 
wandering, 907. 



INDEX. 



1081 



Lobelia, poisoning by, 357. 
Localization of cerebral disease, 
471, 481. 
of spinal disease, 540. 
Locomotor ataxia, 575. 

Argyll-Robertson pupil in, 
580. 

ataxic gait in, 579. 
crises in, 577. 
diagnosis, 581. 
electricity in, 581. 
morbid anatomy, 576. 
prognosis, 582. 
reflexes in, 579. 
stages of, 581. 
suspension in, 585. 
symptomatology, 577. 
treatment, 582. 
tropbic changes in, 580. 
diseases, 44. 
Loeffler's solution, 175. 
Lordosis, 601. 
Louse, 373. 
Lumbago, 74. 
Lump-jaw in cattle, 231. 
Lung-fluke, 336. 
Lungs, acute tuberculosis of, 
247. 
diagnosis, 248. 
examination in, 248. 
onset of, 247. 
prognosis, 249. 
treatment, 292. 
antbracosis of, 756. 
brown induration of, 661, 731. 
cancer of, 767. 
chalicosis of, 756. 
cirrhosis of, 264, 756. 
congestion of, 730. 
diseases of, 730. 
echinococci of, 332. 
embolism of, 733. 
gangrene of, 764. 
gummata in, 311. 
hypostatic congestion of, 731. 
oedema of, 734. 
collateral, 735. 
hypostatic, 735. 
siderosis of, 756. 
splenization of, 731. 
thrombosis of, 733. 
tumors of, 767. 
Lupus, 250. 

treatment, 300. 
Lymph-glands, tuberculosis of, 
281. 

Lymph-scrotum, 341. 
Lymphatic anaemia, 16. 

leukaemia, 13. 
Lymphoma, malignant, 16. 
Lympho-sarcoma, malignant, 

16. 

M. 

Macrocephalus, 512. 
Macroglossia, 795. 
Macropsia, 594. 
Maculosus Werlhofii, 26. 
Madura foot disease, 232. 
Makrophages in malaria, 205. 
Mai de montagne, 417. 



Malarial diseases, 201. 

blood in, 210. 

cachexia, 209. 

diagnosis, 209. 

germ of, 203. 

makrophages in, 205. 

morbid anatomy, 205. 

paroxysms, 205. 

prognosis, 210. 

remittent type, 207. 

symptomatology, 205. 

treatment, 210. 
fever, algid, 208. 

comatose, 208. 

congestive, 208. 

hemorrhagic, 208. 

malignant, 208. 

pernicious, 208. 
Malignant lymphoma, 16. 
lympho-sarcoma. 16. 
malarial fever, 208. 
pustule, 235. 
small-pox, 110, 113. 
Malum senile, 73. 
Mammary gland, tuberculosis 

of, 274. 
Mania, 386, 393. 
chronic, 394. 
epileptic, 422. 
following fevers, 395. 
hallucinatoria, 395. 
periodica, 399. 
puerperal, 395. 
Mania-a-potu, 369. 
Massage, 404. 

Measles, 102. ( Vide Rubeola.) 

black, 104. 

German, 107. 

in swine, 323. 
Mediastinitis, 787. 

indurative, 788. 
Mediastino-pericarditis, 788. 
Mediastinum, diseases of, 787. 
diagnosis, 790. 
treatment, 790. 

tumors of, 789. 
Medulla, diseases of, 536. 

tumors of, 526. 
Megalopsia, 594. 
Megastoma entericum, 322. 
Melancholia, 391. 

agitata, 392. 

attonita, 392. 

hypochondriacal, 392. 

periodica, 399. 

religiosa, 392. 
Melanuria, 999. 
Melasma, suprarenal, 41. 
Melituria, 1009. 

Memory, periodic failure of, 
467. 

Meningitis, 489. 

acute, 489. 

cerebro-spinal, 152. 

chronic, 192. 

occlusive, 490. 

posterior, 490. 

spinal, acute, 516. 

tubercular, 2 10, 491. 

hydrocephalic cry in, 247. 
symptoms, 246. 
Menstrual insanity, 399. 



Merycism, 850. 
Mesoneuritis, 609. 
Micropsia, 594. 
Migraine, 458. 

ophthalmic, 459. 
Miliary fever, 118. 

tubercle, 242. 
Mind-blindness, 487. 
Miryachit, 439. 
Mitral insufficiency, 664. 

stenosis, 665. 
Monophasia, 485. 
Monoplegia, 377. 
Monostoma lentis, 335. 
Moore's test for sugar in urine, 

1010. 

Morbid impulse, 385. 
Morbus coxae senilis, 73. 
Morphoea, 625. 
Morvan's disease, 574. 
Motor centres of brain, 473. 
Movable spleen, 29. 
Mucinuria, 1001. 
Mucous membranes, tuberculo- 
sis of, 250. 
Multiple sclerosis, 522, 

cerebro-spinal, 522. 
Mumps, 183. 

Muscular atrophy, neuritic, 615. 
Charcot-Marie type of, 
616. 

peroneal type of, 616. 
progressive, 569. 
rheumatism, 74. 
sense, 381. 
Myalgia, 74. 
Mycetoma, 232. 
Myelaemia in leukaemia, 15. 
Myelitis, acute, 551. 
diagnosis, 554. 
prognosis, 554. 
softening in, 552. 
stages of, 552. 
symptomatology, 552. 
treatment, 554. 
central, 551. 
centralis, 553. 
cervicalis, 554. 
chronic, 556. 
compression, 558. 
disseminated, 551. 
explosive, 553. 
foudroyant, 553. 
gray, 551. 
hemorrhagic, 551. 
insular, 551. 
Myelogenous leukaemia, 13. 
Myeloma, 19. 
Myiasis, 348. 
Myocarditis, 615. 
prognosis, 6 17. 
treatment, 647. 
Myoma, peritoneal psoudo-, 
974. 

Myomalacia. 6 10. 
Myopathic face, IS. 
Myopathy, atrophic, IS. 
primary, 45. 

pseudo-hypcrtrophie, 16. 
Myositis, 44. 
ossificans progressiva, 44. 
primary, 44. 



1082 



INDEX. 



Myositis, rheumatic, 44. 

suppurative, 44. 
Myotonia, congenital, 49. 
Misophobia, 386. 
Myxoedema, 37. 

treatment, 39. 

N. 

Narcolepsy, 40S, 464. 
Narcotics, poisoning by, 351. 
Nasal catarrh, acute, 701. 

chronic, 703. 
Nelavan, 463. 
Nephrectomy, 993. 
Nephritis, acute, 1022. 

diagnosis, 1025. 

dropsy in, 1023. 

morbid anatomy, 1023. 

prognosis, 1025. 

symptoms, 1023. 

treatment, 1026. 

urine in, 1024. 
acute catarrhal, 1022. 

alteration of heart in, 
1018. 

acute croupous, 1022. 
acute desquamative. 1022. 
acute diffuse, 1022.' 
acute parenchymatous, 1022. 
chronic diffuse, 1028. 

diagnosis, 1030. * 
morbid anatomy, 1028. 
prognosis, 1031. 
symptoms, 1029. 
treatment, 1031. 
urine in, 1029. 
chronic fibrous, 1033. 

albuminuric retinitis in, 

1036. 
diagnosis, 1036. 
dys]3noea, 1036. 
hvpertrophv of heart in. 

'1034, 1035. 
morbid anatomy, 1033. 
prognosis, 1037. 
symptoms, 1034. 
treatment, 1037. 
urine in, 1035. 
chronic interstitial, 1033. 

parenchymatous. 1028. 
glomerular, i022. 
glomerulo-capsular, 1022. 
suppurative, 1040. 
Nephrolithiasis, 1053. 
diagnosis, 1055. 
passage of stone in, 1054. 
prognosis, 1055. 
symptoms, 1054. 
treatment, 1056. 
Nephroptosis, 9S9. 
Nephrorrhaphy, 993. 
Nerve, syphilis of, 618. 
Nervous diseases, functional, 
889. 
dyspepsia, 852. 
Neuralgia, 468. 
diagnosis, 470. 
of bladder, 1058. 
of heart, 682. 
treatment, 470. 
Neurasthenia, 400. 



Neurasthenia, diet in, 403. 

massage, 404. 

rest-cure, 402. 

treatment, 401. 
Neuritic muscular atrophy, 615. 
Neuritis, 603. 

alcoholic, 607. 

diabetic, 607. 

multiple, 605. 

parenchymatous, 605. 

post-febrile, 608. 

segmentary, 606. 

senile, 608. 
Neuroma, 617. 
Neuroses, cardiac, 678. 

occupation, 454. 

traumatic, 446. 
Night palsy, 464, 623. 
Night-sweats in phthisis, 299. 
Night-terrors, 465. 
Nitric acid, poisoning by, 360. 

test in albuminuria, 1002. 
Xitrites, poisoning by, 357. 
Nitro-benzol, poisoning by, 352. 
Nitrohydrochloric acid, poison- 
ing by, 360. 
Noma, 792. 
Nose, diseases of, 700. 
Nosebleed, 700. 
Note-blindness, 485. 
Nucleoalbuminuria, 1001, 1005. 
Nyctalopia, 933. 
Nymphomania, 386. 



o. 

Obesity, 58. 
Obstipation, 903. 
Occipital lobe, tumors of, 526. 
I Occupation neuroses, 454. 
j CEdema, angioneurotic, 622. 
neonatorum, 625. 
OZsophagismus, 815. 
! Oesophagitis, 809. 
catarrhal, 810. 
corrosive, 810. 
diphtheritic, 810. 
dissecans superficialis, 810. 
fibrinous, 810. 
follicular, 810. 
phlegmonous, S10. 
OZsophagus, cancer of, 812. 
diagnosis, 814. 
symptoms, 813 
treatment. 814. 
dilatation of, 806. 
diseases of, 804. 
diverticulum, 807. 
pulsion, 817. 
traction, 808. 
ectasia of, 806. 
inflammation of, 809. 
obstruction of, 804. 
paralysis of, 815. 
perforation of, 808. 
rupture of, 809. 
spasm of, 815. 
stenosis of, 804. 
stricture of, 804. 
tumors of, 812. 
O'idium albicans, 792. 
Oliguria, 1015. 



Omodynia, 74. 
Ophthalmic migraine, 459. 
Ophthalmoplegia, 595. 

externa, 595. 

interna, 595. 

progressiva, 595. 
Opium, poisoning by, 351. 

treatment, 353. 
Opiumism, 374. 

treatment, 375. 
Optic disk in cerebral disease, 
477. 

thalamus, tumors of, 526, 

Osteitis deformans, 626. 

Osteo-arthropathy, hypertro- 
phic, 723. 

Osteomalacia, 56. 
infantile, 57. 
puerperal, 57. 
senile, 57. 

Osteomyelitis tuberculosa, 285. 

Osteoporosis, 524. 

Ovaries, tuberculosis of, 274. 

Oxalic acid, poisoning by, 360. 

Oxaluria, 1007. 

Oxyuris vermicularis, 338. 

P. 

Pachydermia laryngis, 710. 
Pachymeningitis, 488. 

cervical, 547. 

externa, 488. 

interna, 488. 

haemorrhagica, 488. 

spinal, acute, 546. 
Painless tic, 431. 
Palpitation of heart, 676, 678. 
Palsy, Bell's, 611. 

bulbar, 537. 

cerebral, of children. 508. 
night, 623. 
pressure, 603. 
wasting, 570. 
Pancreas, cancer of, 960. 
cysts of, 957. 
contents, 958. 
diagnosis, 959. 
prognosis, 960. 
symptoms, 958. 
treatment, 960. 
diseases of, 950. 
hemorrhage of, 950. 
tuberculosis of, 269. 
Pancreatic calculi, 955. 
Pancreatitis, acute, 951. 
diagnosis, 953. 
symptoms, 952. 
treatment, 954. 
chronic, 954. 
gangrenous, 951. 
hemorrhagic, 951. 
suppurative, 952. 
Paraesthesia, 382. 
Parageusia, 477. 
Paragraphia, 485. 
Paralexia, 485. 
Paralysis, 377. 

acute ascending, 548. 
a git an s, 444. 
Bell's, 611. 
brachial, 377. 



INDEX. 



1083 



Paralysis, bulbar, 537. 
cerebral, of children, 508. 
complete, 377. 
crossed, 377. 
crural, 377. 
facial, 377. 

following diphtheria, 169. 
following typhoid fever, 133. 
general, 377. 
general, of insane, 516. 
hysterical, 408. 
incomplete, 377. 
infantile spastic, 508. 
labial, 537. 
Landry's, 548. 
local, 377. 
multiple, 377. 
oculo-motor, 594. 
of abducens nerve, 595. 
of anterior crural nerve, 601. 
of anterior thoracic nerve, 
599. 

of auditory nerve, 596. 
of circumflex nerve, 599. 
of eighth cranial nerve, 596. 
of external popliteal nerve, 
602. 

of facial nerve, 596. 
of fifth cranial nerve, 595. 
of fourth cranial nerve, 595. 
of glosso-pharyngeal nerve, 
598. 

of gluteal nerve, 602. 
of ilio-hypogastric nerve, 
601. 

of ilio-inguinal nerve, 601. 
of insane, 516. 
of intercostal nerve, 601. 
of internal popliteal nerve, 
603. 

of laryngeal muscles, 597. 
of long thoracic nerve, 598. 
of median nerve, 600. 
of musculo-cutaneous nerve, 
599. 

of musculo-spiral nerve, 599. 
of obturator nerve, 602. 
of oculo-motor nerve, 594. 
of oesophagus, 815. 
of pneumogastric nerve, 597. 
of sciatic nerve, 602. 
of seventh cranial nerve, 596. 
of sixth cranial nerve, 595. 
of spinal accessory nerve, 
598. 

of spinal nerves, 601. 

of subscapular nerve, 599. 

of suprascapular nerve, 599. 

of third cranial nerve, 594. 

of trigeminus nerve, 595. 

of trochlear nerve, 595. 

Of ulnar nerve, 600. 

periodic, 429. 
Paralytic stroke, 498. 
Paramusia, 485. 
Paramyoclonus multiplex. 444. 
Paramyotonia congenita, 50. 
Paranephritic abscess, 1051. 
Paranephritis, suppurative, 

1051. 
Paranoia, 398. 
Paraphasia, 485. 



Paraplegia, ataxic, 588. 

spastic, 585. 
Parasites, 321. 
Parasitic insects, 346. 

protozoa, 321. 
Paratyphlitis, 876. 
Paresis, 377, 516. 
Paretic dementia, 516. 
Parietal lobes, tumors of, 526. 
Parorexia, 850. 
Parotitis, 796. 

epidemic, 186. 
Pediculus capitis, 346. 
pubis, 346. 
vestimentorum, 346. 
Peliosis rheumatica, 25. 
Pentastoma denticulatum, 345. 
taenioides, 345. 
constrictum, 346. 
Pentastomum, 345. 
Peptonuria, 1001, 1005. 
Perforating ulcer, 621. 
Periarteritis, nodular, 692. 
Pericarditis, 630. 
course, 633. 
diagnosis, 634. 
paracentesis in, 635. 
physical examination, 632. 
prognosis, 634. 
symptoms, 632. 
treatment, 634. 
chronic, 635. 
dry, 613. 
obliterative, 636. 
sicca, 631. 
tubercular, 275, 631. 
Pericardium, diseases of, 628. 
Periencephalitis, acute, 513. 
diagnosis, 514. 
prognosis, 515. 
treatment, 515. 
chronic, 516. 

convulsions in, 518. 
diagnosis, 520. 
handwriting in, 520. 
paralysis in, 519. 
prognosis in, 521. 
stages of, 518. 
symptomatology, 517. 
treatment, 521. 
idiopathic, 513. 
septic, 513. 
Periencephalo-meningitis, 516. 
Perihepatitis, 914. 

acute suppurative, 914. 
diagnosis, 916. 
prognosis, 916. 
treatment, 916. 
chronic, 916. 
Perinephritic abscess, 1015. 
Perineuritis, 603. 
Periodical insanity, 399. 

paralysis, 429. 
Peripheral encephalitis, acute, 
513. 

Peripleuritis, 783. 
Perisplenitis, 29. 
Peristaltic unrest, 851. 
Peritoneum, cancer of, 986. 

diseases of. !M>2. 

cchinococci of, 334. 

inflammation of, 972. 



Peritoneum, tuberculosis of, 276. 
diagnosis, 279. 
laparotomy in, 300. 
morbid anatomy, 277. 
prognosis, 280. 
symptoms, 278. 
treatment, 300. 
tumors of, 986. 
Peritonitis, 972. 
acute, 973. 

cathartics in the treatment 

of, 981, 983. 
diagnosis, 978. 
morbid anatomy, 974. 
prognosis, 979. 
results, 978. 
symptoms, 975. 
treatment, 980. 
chronic, 983. 
granular, 984. 
serous, 984. 
diagnosis, 985. 
treatment, 9S5. 
idiopathic, 973. 
infectious, 973. 
primary, 973. 
rheumatic, 973. 
secondary, 973. 
septic, 973. 
simple, 973. 
spontaneous, 973. 
Perityphlitis, 876. 
Pernicious anaemia, 9. 

fever, 208. 
Persecution, delusions of, 385. 
Personality, double, 467. 
Pertussis, 179. ( Vide Whoop- 

ing-Cough.) 
Phantom tumor, 412. 
Pharyngeal tonsil, 801. 
Pharyngitis, acute, 798. 
catarrhal, 800. 
phlegmonous, 799. 
sicca, 800. 
Pharynx, inflammation of, 797. 
Phlegmonous erysipelas, 187. 
Phosphatic diabetes, 1008. 
Phosphaturia, 1008. 
Phosphorus, poisoning by, 361. 
Phrenitis mania gravis, 513. 
Phthisis, acute pulmonary, 254. 
cough in, 255. 
diagnosis, 256. 
laryngitis in, 255. 
physical signs in, 255. 
prognosis, 256. 
sputum, 255. 

staining of, 256. 
temperature in, 254. 
treatment, 292. 
advanced, 258. 
chronic pulmonary, 256. 
cavity in, 261. 
course, 261. 
diagnosis, 263. 
duration. 261, 262. 
examination, 257, 259. 
fever of, 261 . 
hremio murmur in, 261. 
haemoptysis in, 259. 
intestinal ulcer in, 262. 
menstruation in, 262. 



1084 



INDEX. 



Phthisis, chrome pulmonary, 
pain in, 258. 
prognosis. 263. 
sputum. 258. 
treatment. 292. 
urine in. 262. 
fibroid, 264. 
incipient, 257. 
laryngeal, 263. 
pulmonary, 251. 
cavity in, 252. 
cheesy bronchitis in, 253. 
cheesy pneumonia in, 253. 
morbid anatomy, 252. 
pleura in, 254. 
pneumothorax in, 253. 
symptoms, 254. 
treatment, 292. 
Pica, 850. 
Pin-worm, 338. 

Pitres, pediculo-frontal band of, 

Plague. 162. 

British, US. 
Pleura, diseases of, 770. 
echinococci of, 332. 
tuberculosis of, 276. 
tumors of, 787. 
Pleurisy. 775. 
Pleuritis. 775. 

bacteria in, 776. 
diagnosis, 782. 
dry treatment, 785. 
morbid anatomy, 777. 
paracentesis thoracis, 785. 
perforation in, 778. 
physical examination, 780. 
prognosis, 784. 
symptoms, 779. 
treatment. 784. 
chronic, 778. 

relations to tuberculosis, 
776, 784. 
diaphragmatic, 777. 
dry, 777. 
encysted, 777. 
fibrino-serous, 777. 
fibrinous, 777. 
hemorrhagic, 777. 
ichorous, 777. 
interlobular, 777. 
latent, 779. 
metapneumonic, 776. 
primary. 775. 
secondary, 775. 
sero-fibrinous, 777. 
serous, 777. 
Pleurodynia, 74. 
PI euro-pneumonia. 747. 
Plica Polonica. 347. 
Plumbic acetate, poisoning by, 
361. 

Pneumonia, abortive, 747. 
acute, 741. 

bacillus of. 742. 
blood in. 746. 
complications of, 747. 
diagnosis. 74S. 
engorgement in, 742. 
gangrene in, 743. 
hepatization in, 742. 
morbid anatomy, 742. 



Pneumonia, acute, physical e; 
amination, 745. 
prognosis, 748. 
resolution in, 743. 
sputum in, 745. 
stages of, 742. 
symptoms, 743. 
treatment, 749. 
varieties, 746. 
apical, 747. 
central, 747. 
cerebral, 747. 
cheesy, 252. 
chronic fibrous, 755. 
diagnosis, 758. 
etiology, 757. 
morbid anatomy, 757. 
prognosis, 758. 
symptoms, 757. 
treatment, 758. 
chronic interstitial, 755. 
croupous, 741. 
ephemeral, 747. 
fibrinous, 741. 
hypostatic, 731. 
lobar, 741. 
typhoid, 746. 
wandering, 747. 
Pneumonokoniosis, 756. 
Pneumo-pericardium, 628. 
Pneumothorax, 770. 
circumscribed, 770. 
coin sound in, 772. 
diagnosis, 772. 
diffused, 770. 
morbid anatomy, 770. 
physical examination, 771. 
prognosis, 772. 
symptoms, 771. 
treatment. 772. 
Podagra. 78. 
Poisoning, acute, 350. 
aconite, 358. 
alcohol, 351. 
antimony, 360. 
arsenic, 360. 
atropine, 355. 
delirifacients, 355. 

treatment, 355. 
narcotics, 351. 

artificial respiration, 354. 
law of crossed action, 354. 
treatment, 353. 
Calabar bean. 357. 
cantharides, 361. 
carbolic acid, 352. 

antidote, 353. 
cardiants, 358. 
chloral, 351. 
chloroform, 352. 
citric acid, 360. 
cocaine, 355, 356. 
conium, 358. 
convulsants. 356. 
corrosive sublimate. 360. 
cupric sulphate, 361. 
ether, 352. 
gelsemium, 358. 
hydrochloric acid, 360. 
hyoscine. 355. 
hyoscyamine, 355. 
illuminating gas, 351. 



:- Poisoning, acute, irritants, 360. 
lobelia, 357. 
nitric acid, 360. 
nitrites, 357. 
nitro-benzol, 352. 
nitrohydrochloric acid, 

360. 
oil of rue, 361. 
oil of savine, 361. 
oil of tansy, 353. 
opium, 351. 

treatment, 353. 
oxalic acid, 360. 
paralyzants, 357. 

treatment, 358. 
pelletierine, 358. 
phosphorus. 361. 
plumbic acetate, 361. 
prussic acid, 352. 
santonin, 352. 
Spanish fly, 361. 
strychnine, 356. 

treatment, 357. 
sulphuric acid, 360. 
tartaric acid, 360. 
veratrum viride, 358. 
woorari, 358. 
chronic, 362. 
alcohol, 368. 
antimony, 368. 
arsenic, 367. 
cocaine, 376. 
lead, 362. 

treatment, 366. 
opium, 374. 
Polioencephalitis, 509. 

superior, 510. 
Poliomyelitis, acute, 560. 
deformity in, 564. 
diagnosis, 564. 
electricity in, 567. 
paralysis in. 562. 
reaction of degeneration in, 
563. 

symptomatology, 562. 
treatment, 565. 
ascending, 568. 
chronic. 569. 
metallic, 568. 
Polysesthesia, 579. 
Polyarthritis, rheumatic, 61. 
Polymyositis, acute, 44. 
Polyphagia, 850. 
Pons, tumors of, 526. 
Porencephalia, SOS. 
Post-febrile insanity, 395. 
Potassium ferrocyanide test in 

albuminuria. 1002. 
Precordial anguish, 392. 
Pregnancy, chorea of, 437. 
Pressure palsy, 603. 

sense, 381. 
Primary curable dementia, 395. 
myopathy, 45. 
myositis. 44. 
i Prison fever, 145. 
' Proeressive muscular atrophy, 
I 569. 

pernicious anamiia, 9. 
; Prostate, tuberculosis of, 272. 

Protozoa, 321. 
j Prussic acid, poisoning by, 352. 



INDEX. 



1085 



Pseudo-diphtheria, 171. 
Pseudo-leukaemia, 16. 
Pseudo-muscular hypertrophy, 
45. 

Psorosperms, 349. 
Psychical anaesthesia, 391. 

dysthesia, 391. 

hyperesthesia, 391. 
Puerperal insanity, 515. 

mania, 395. 

osteomalacia, 57. 
Pulex irritans, 348. 
Pulmonary consumption, 251. 

gangrene, 764. 

hemorrhage, 732. 

insufficiency, 668. 

phthisis, 251. 
acute, 254. 
chronic, 256. 

stenosis, 668. 

valve, disease of, 668. 
Pupil, Argyll-Robertson, 478, 

580. 

Pupils in cerebral disease, 478. 
Purpura, 24. 

fulminans, 27. 

haemorrhagica, 26. 

Henoch's, 26. 

rheumatic, 25. 

simple, 24. 

symptomatic, 20. 
Pustule, malignant, 235. 
Pyaemia, 191. 

diagnosis, 193. 

treatment, 194. 
Pyelitis, 1045. 

diagnosis, 1047. 

morbid anatomy, 1046. 

prognosis, 1048. 

symptoms, 1047. 

treatment, 1048. 
Pyloric incompetency, 851. 
Pyonephrosis, 1048. 
Pyopneumothorax, 771. 
Pyosepticaemia, 191. 
Pyromania, 386. 
Pyuria, 1015. 

Q- 

Quinsy, 802. 

R. 

Rabies, 233. 

diagnosis, 234. 

dumb, 233. 

furious, 233. 

prognosis, 234. 

treatment, 234. 
Rachitis, 50. 
Ranula, 795. 

Raptus melancholicus, 392. 
Ray-fungus in actinomycosis, 
231. 

Raynaud's disease, 619. 

chronic, 621. 
Reaction of degeneration, law 

of, 563. 
Reflexes, 378. 

ankle, 378. 

deep, 378. 

patella, 378. 



Reflexes, reinforcement of, 378. 

superficial, 378. 
Regurgitation, 850. 
Relapsing fever, 149. 
Remittent fever, 207. 
Renal calculus, 1053. 

composition of, 1053. 

cysts, 1042." 

phthisis, 270. 
Rest-cure in neurasthenia, 402. 
Retropharyngeal abscess, 799. 
Rheumatic arthritis, chronic, 
70. 

fever., 61. 

gout, 71. 

polyarthritis, 61. 

purpura, 25. 
Rheumatism, acute articular, 
61. 

complications of, 64. 
cutaneous eruptions in, 
65. 

diagnosis, 65. 
duration, 64. 
germ theory of, 62. 
prognosis, 66. 
symptoms, 63. 
treatment, 66. 

cerebral, 65. 

chronic articular, 70. 

gonorrhceal, 68. 

muscular, 74. 

scarlatinal, 98. 

subacute, 64. 
Ptheumatoid arthritis, 71. 
Rhinitis, acute, 701. 

chronic, 703. 
Rickets, 50. 

diagnosis, 53. 

feeding in, 54. 

foetal, 50 (note). 

hemorrhagic, 55. 

prognosis, 53. 

treatment, 53. 
Romberg's symptom, 579. 
Rose-cold, 704. 
Rotheln, 107. 
Round worms, 337. 
Rubeola, 102. 

black form of, 1 04. 

complications of, 104. 

diagnosis, 105. 

hemorrhagic, 104. 

malignant forms of, 104. 

prognosis, 105. 

treatment, 105. 
Rue, oil of, poisoning by, 361. 

S. 

Salaam convulsions, 439. 

Salivary glands, inflammation 
of, 796. 

Sand-flea. 348. 

Santonin, poisoning by, 352. 

Sapiaeinia, 189. 

Sarcopsylla penetrans, 348. 

Sarcoptes hominis, 346. 

Saturnine ccrebritis, 363. 

Savine, oil of, poisoning by, 361. 

Scapulo-humeral type of atro- 
phic myopathy, 48. 



Scarlatina, 95. 

complications, 98. 

diagnosis, 99. 

diphtheria in, 98. 

eruption in, 96. 

fever in, 101. 

maligna, 98. 

nephritis in, 95, 99. 

prognosis, 100. 

simple, 97. 

tongue in, 96. 

treatment, 100. 
Scarlet fever, 95. 
Schoenlein's disease, 25. 
Sciatica, 609. 
Sclerema neonatorum, 625. 
Sclerodactylia, 625. 
Scleroderma, 623. 
Scleroses, combined, 588. 
Sclerosis, amyotrophic lateral, 
588. 

antero-lateral, 585. 

disseminated, 521. 

multiple cerebro-spinal, 522. 
Scoliosis, 601. 

paralytica, 601. 
Scorbutus, 22. 
Scotomata, 480. 
Scrofula, 285. 

bones in, 289. 

catarrh in, 288. 

diagnosis, 290. 

etiology, 287. 

lymph-glands in, 289. 

morbid anatomy, 287. 

prognosis, 290. 

symptomatology, 288. 

types of children with, 289. 
Scrofuloderma, 250. 

treatment, 300. 
Scurvy, 22. 

infantile, 50. 
Secondary anaemia, 3. 
Seminal vesicles, tuberculosis 

of, 272. 
Senile osteomalacia, 57. 
Sensation, disturbances of, 381. 
Sense-shock, 464. 
Septic infection, 189. 

intoxication, 189. 

toxaemia, 189. 
Septicaemia, 189. 
Septico-pyaemia, 191. 
Serous membranes, tuberculosis 

of, 275. 
Ship fever, 145. 
Siderosis of lungs, 756. 
Silvester's method of artificial 

respiration, 354. 
Simple anaemia, 2. 
Singultus, 416. 
Skin, tuberculosis of, 250. 
Sleep, disorders and accidents 
of, 4 (id, 463. 

morbid. 463. 

Smallpox. 109. ( Vide Variola*) 

black, 113. 

hrmorrhagic, 110, II 

malignant, 110, 113. 
Smell, centre for, 476. 
Softening of brain, 518. 
Somnambulism, 465. 



1086 



INDEX. 



Soul-blindness, 487. 

Spanish fly, poisoning by, 361. 

Spasm, 379. 

facial, 431. 

local, 431. 

nodding, 432. 

rotary, 432. 
Spastic paralysis, infantile, 508. 

paraplegia, 585. 
Spinal abscess, 547. 

anaemia, 409, 545. 

apoplexy, 543. 

convulsions, 378. 

cord, anatomy of, 540. 
hyperemia of, 545. 
tuberculosis of, 284. 

embolism, 544. 

epilepsy, 586. 

hemorrhage, 543. 

irritation, 409. 

localization, 540. 

meningitis, acute, 546. 
chronic, 547. 

pachymeningitis, 546. 

syphilis, 592. 

thrombosis, 544. 

tumor, 548. 
Spirillum Obermeieri in re- 
lapsing fever, 149. 
Splanchnoptosis, 29, 855. 
Spleen, abscess of, 30. 

diseases of, 28. 

embolism of, 30. 

enlargement of, 28. 

movable, 29. 

tuberculosis of, 281. 

wandering, 29. 
Splenic anaemia, 16. 
Splenoptosis, 29. 
Sporozoa, 321. 

of malaria, 203. 
Spotted fever, 152. 
Sputa, nummulated, 258. 
Sputum, staining of, in phthisis, 

255. 

Station test, 380. 
Stomach, atony of, 851. 
cancer of, 843. 
cachexia in, 846. 
diagnosis, 847. 
examination of contents in, 
848. 

extension of, 845. 

morbid anatomy, 844. 

prognosis, 848. 

symptoms, 845. 

treatment, 848. 

tumor in, 846. 

urine in, 847. 

vomiting in, 845. 
cramp of, 851. 
dilatation of, 823. 
examination of contents of, 
820. 
in cancer, 847. 
hyperacidity of, 852. 
hyperesthesia of, 850. 
inflation of, 817. 
malposition of, 822. 
neuroses of, 849. 

of motility, 850. 

of secretion, 852. 



' Stomach, neuroses of sensation, 
849. 

peracidity of, 852. 
peristaltic unrest of, 851. 
physical examination of, 818. 
spasm of, 851. 
superacidity of, 852. 
ulcer of, 836. 

chronic, 837. 

diagnosis, 840. 

gastralgia in, 842. 

haematemesis in, 839, 842. 

morbid anatomy, 837. 

perforation in, 840, 843. 

prognosis, 841. 

symptoms, 837. 

treatment, 841. 
Stomatitis, 791. 
aphthous, 791. 
catarrhal, 791. 
gangrenous, 791. 
parasitic, 792. 
symptoms, 792. 
treatment, 793. 
ulcerative, 792. 
Strawberry tongue in scarla- 
tina, 96. 
Streptococcus erysipelatis, 185. 

pyogenes, 185. 
Striated bodies, tumors of, 526. 
Strongylus longivaginatus, 339. 
Struma, 31. 

Strychnine, poisoning by, 356. 
Stupor, 460. 

delusional, 395. 
St. Vitus's dance, 432. 

diagnosis, 436. 

prognosis, 436. 

symptomatology, 434. 

treatment, 436. 
Subacute rheumatism, 64. 
Sublingual glands, inflamma- 
tion of, 796. 
Submaxillary glands, inflam- 
mation of, 796. 
Subphrenic abscess, 914. 

pyopneumothorax, 914. 
Sugar in urine, test for, 1010. 
Sulphuric acid, poisoning by, 

360. 
Sunstroke, 450. 
Suppurative encephalitis, 510. 

myositis, 44. 
Suprarenal capsules, tuberculo- 
sis of, 619. 

melasma, 41. 
Surgical insanity, 395. 
Symmetrical gangrene, 619. 
Symptomatic purpura, 20. 
Syncope, local, 619. 
Syphilide, macular, 307. 

papular, 307. 

pustular, 308. 

tubercular, 309. 
Syphilis, 304. 

acquired, 306. 
alopecia in, 308. 
choroiditis in, 309. 
eruption of, 307. 
exostosis in, 309. 
gumma in, 310. 
hard chancre in, 306. 



Syphilis, acquired, Huntexian 
chancre in, 306. 
iritis in, 309. 
macular syphilide, 307. 
nodes in, 309. 
papular syphilide, 307. 
periostitis in, 309. 
pustular syphilide, 308. 
secondary stage, 307. 
tertiary stage, 309. 
tubercular syphilide, 309. 
visceral, 311. 
bacilli of, 304. 
cerebral, 528. 
age in, 533. 

convulsions in, 529, 531. 

diagnosis, 532. 

gumma in, 528. 

headache in, 530. 

insomnia in, 530. 

palsy in, 529, 531. 

prodromes, 532. 

prognosis, 534. 

treatment, 534. 
Colles's law, 304. 
gumma in, 305. 
hereditary, 312. 

diagnosis, 315. 

infantile, 314. 

intra-uterine infection, 
313. 

marriage in, 317. 

morbid anatomy, 313. 

osteochondritis in, 313. 

prognosis, 316. 

prophylaxis, 316. 

symptoms, 314. 

treatment, 317. 
of cachexia, 320. 
morbid anatomy, 305. 
of arteries, 311. 
of heart, 311. 
of liver, 311. 
of lungs, 311. 
of nerves, 618. 
of testis, 312. 
spinal, 592. 
Syphiloma, 305. 
Syringomyelia, 572. 
diagnosis, 575. 
gliosis in, 573. 
prognosis, 575. 
symptomatology, 573. 
treatment, 575. 
trophic changes, 575. 



T. 

Tabes, 575. 

mesenterica, 266. 

meseraica, 266. 
Tabetic anthropathy, 580. 
Taches bleuatres, 347. 
Tachycardia, 679. 
Taenia acanthotrias, 324. 

cucumerina, 324. 

echinococcus, 329. 

elliptica, 324. 

flavo-punctata, 324. 

madagascariensis, 324. 

mediocanellata, 324. 

nana, 324. 



INDEX. 



1087 



Taenia saginata, 324. 

solium, 323. 
Tansy, oil of, poisoning by, 353. 
Tape-worms, 323. 

diagnosis, 326. 

etiology, 324. 

symptoms, 325. 

treatment, 326. 
Tartaric acid, poisoning by, 360. 
Taste, centre for, 476. 

loss of, 477. 
Temporal lobe, tumors of, 526. 
Terminal dementia, 397. 
Testes, scrofula of, 273. 

syphilis of, 312. 

tuberculosis of, 273. 
Tetanic convulsions, 378. 
Tetanus, 194. 

antitoxin in, 200. 

bacillus of, 194. 

cerebral, 198. 

diagnosis, 198. 

idiopathic, 198. 

neonatorum, 198. 

opisthotonos in, 197. 

prognosis, 198. 

symptomatology, 196. 

treatment, 199. 
Tetany, latent, 443. 

treatment, 443. 
Thermic fever, 450. 
bathing in, 453. 
diagnosis, 452. 
sequelae, 454. 
treatment, 452. 

sensibility, 381. 
Thomsen's disease, 49. 
Thread-worms, 337. 
Thrombosis, cerebral, 494. 

of cerebral sinus, 497. 

of heart, 648. 
Thymic asthma, 40. 
Thymus gland, diseases of, 40. 
tuberculosis of, 283. 
tumors of, 40. 
Thyroid gland, diseases of, 31. 
tuberculosis of, 283. 
tumors of, 40. 
Tic, 431. 

choreic, 438. 

convulsif, 439. 

convulsive, 431. 

douloureux, 431, 613. 

painless, 431. 

salaam, 439. 
Ticks, 346. 
Titubation, 381, 488. 
Tongue, dissected, 794. 

geographic, 794. 

ichthyosis of, 794. 

keratosis of, 794. 

©edematous enlargement of, 
795. 

psoriasis of, 794. 
Tongue-deafness, 485. 
Tonsils, inflammation of, 797. 

pharyngeal, 801. 
Tonsillitis, 801. 

acute, 801. 

chronic, 803. 
Torticollis, 431. 

rheumatic, 24. 



Trachea, diseases of, 712. 
Trachitis, 712. 
Trance, hysterical, 408. 
Traumatic back, 447. 

neurosis, 446. 
diagnosis, 448. 
treatment, 449. 
Tremor, 380. 

intention, 380. 

persistent, 380. 
Trichina spiralis, 342. 
Trichinosis, 342. 

diagnosis, 344. 

symptoms, 344. 

treatment, 345. 
Trichocephalus dispav, 340. 
Trichomonas intestinalis, 322. 

vaginalis, 322. 
Tricuspid insufficiency, 667. 

stenosis, 668. 
Trigeminal nerve, inflammation 

of, 613. 

Trommer's test for sugar in 

urine, 1010. 
Trophic disturbances, 382. 
Tropical anaemia, 3. 

dysentery, 212. 
Tubal tuberculosis, 274. 
Tubercle, 242. 
anatomist's, 250. 
miliary, 242. 
Tubercula dolorosa, 618. 
Tuberculin, 241. 
Tuberculosis, 239. 

antiphthisin in, 241. 
bacillus of, 239, 241. 
caseation in, 243. 
cheesy degeneration in, 
243. 

cheesy metamorphosis in, 
243. 

miliary tubercle in, 242. 
morbid anatomy, 242. 
predisposing causes, 241. 
primary, 240. 
secondary, 240. 
symptoms, 244. 
treatment, 292. 
varieties, 244. 
acute or disseminated, 244. 
morbid anatomy, 245. 
prophylaxis, 290. 
symptomatology, 245. 
temperature in, 245. 
treatment, 292. 
chronic general, 248. 
prophylaxis, 290. 
treatment, 292. 

alcohol, 294. 

climate, 295. 

counter- irritation, 297. 

exercise, 294. 

food, 294. 

germicides, 293. 

inhalations, 297. 

internal medication, 297. 

of fever, 299. 

of glands, 293. 

of hemoptysis, 298. 

of night-sweats, 299. 

pulmonary gymnastics, 



Tuberculosis, chronic, tubercu- 
lin treatment, 293. 
local, 249. 

of alimentary canal, 265. 

of bladder, 271. 

of blood-vessels, 283. 

of bones, 285. 

of brain, 284. 

of ductless glands, 281. 

of Fallopian tubes, 274. 

of heart, 283. 

of intestines, 265. 

of joints, 285. 

of kidney, 270. 

of liver, 268. 

of lungs, 247. 
diagnosis, 248. 
examination in, 248. 
onset of, 247. 
prognosis, 249. 
treatment, 292. 

of lymph -glands, 281. 

of mammary gland, 274. 

of mucous membranes, 250. 

of ovaries, 274. 

of pancreas, 269. 

of pericardium, 275. 

of peritoneum, 276. 

of pleura, 276. 

of prostate, 272. 

of seminal vesicles, 272. 

of serous membranes, 275. 

of sexual organs of females, 
273. 

of skin, 250. 

of spinal cord, 284. 

of spleen, 281. 

of suprarenal capsule, 283. 

of testicle, 273. 

of thymus, 283. 

of thyroid, 283. 

of uro-genital tract, 269. 

of uterus, 274. 

of vascular system, 283. 

pulmonary, 251. ( Vide 
Phthisis, pulmonary. j 
Tumors, intracranial, 524. 

diagnosis, 527. 

epileptic attacks in, 525. 

knee-jerk in, 527. 

treatment, 528. 
of biliary tract, 947. 
of heart, 650. 
of intestines, 894. 
of kidneys, 1043. 
of larynx, 711. 
of lungs, 767. 
of mediastinum, 789. 
of oesophagus, 812. 
of peritoneum, 986. 
of pleura, 787. 
of thymus gland, 40. 
of thyroid, 40. 
phantom, 412. 
spinal, 548. 
Tuphlo-enteritis, 876. 
i Typhlitis, 876. 
Typhoid, bilious, 151. 
face, 125. 
fever, 119. 

abortive, 130. 

apyretic, 130. 



1088 



INDEX. 



Typhoid fever, afebrile, 130. 
ataxic, 130. 
bacillus of, 119, 135. 
bathing in, 141. 
bilious, 129. 
complications of, 131. 
convalescence in, 133. 
crisis in, 124. 
delirium in, 125. 
diagnosis, 133. 
diet in, 139. 
Ehrlich's test, 134. 
eruption in, 123. 
foudroyant, 130. 
gastric, 129. 
hemorrhagic, 129. 
intestinal hemorrhage in, 
128. 

morbid anatomy, 121. 
perforation in, 122, 128, 
144. 

Peyer's patches in, 121, 143. 
prognosis, 135. 
prophylaxis, 137. 
pulse in, 126. 
relapse in, 124. 
sequelae of, 131, 133. 
solitary follicles in, 121. 
special symptoms of, 126. 
spleen in, 122, 128. 
stools in, 127. 
symptomatology, 123. 
temperature in, 126. 
treatment, 138. 

feeding, 13S. 

of accidents, 142. 

of fever, 140. 

of peritonitis, 144. 

of symptoms, 142. 
urine in, 129. 

varieties of, 129. 

walking, 130. 
pneumonia, 746. 
Typho-malarial fever, 132. 
Typhomania, 513. 
Typhus biliosus, 151. 
fever, 145. 

diagnosis/148, 
eruption in, 147. 
face in, 145. 
prognosis, 148. 
symptomatology, 148. 
treatment, 148. 

U. 

Ulcer, corrosive, 837. 
of stomach, 836. 

diagnosis, 840. 

gastralgia in, 838, 842. 

hemorrhage in, 839, 842. 

prognosis, 841. 

symptoms, 838. 

treatment, 841. 
peptic, 837. 
perforating, 621, 837. 
Uraemia, 1015. 
diagnosis, 1017. 
in congestion of kidneys, 

1020. 

in chronic diffused nephritis, 
1030. 



Uraemia in chronic fibrous ne- 
phritis, 1038. 
prognosis, 1017. 
I Uraturia, 1006. 
| Uricacidaemia, 80. 
| Uricaciduria, 1006. 
| Urica?mia, 80. 
Urine, abnormalities of, 994. 
albumin in, 1001. 

tests for, 1002. 
blood in, 994. 
casts in, 1013. 
color of, 994. 
cylindroids in, 1013. 
in acute yellow atrophy 

of liver, 917. 
in amyloid degeneration 

of kidney, 1039. 
in cancer of liver, 930. 
in cancer of stomacb, 

847. 
in chlorosis, 5. 
in cystitis, 1059. 
in diabetes insipidus, 93. 
in diabetes mellitus, 88. 
in endocarditis, chronic, 
662. 

in floating kidney, 991. 
in hydronephrosis, 1049. 
in hysteria, 410. 
in lead poisoning, 336. 
in nephritis, acute, 1024. 
chronic diffuse, 1029. 
chronic fibrous, 1033. 
in phthisis, 262. 
in pneumonia, 746. 
in pyelitis, 1047. 
in renal tuberculosis, 271. 
in rheumatism, 63. 
in scarlatina, 99. 
in tuberculosis, 246. 
in typhoid fever, 129. 
in yellow fever, 229. 
incontinence of, paralvtic, 
1057. 
spasmodic, 1057. 
sugar in, test for, 1010. 
Urobilinuria, 998. 
Uro-genital tuberculosis, 269. 
Urticaria, giant, 622. 
Uterus, tuberculosis of, 274. 

V. 

Vaccination, 116. 

operation for, 117. 
Vaccinia, 116. 
Vagabond's disease, 347. 
Variola, 109. 

black, 113. 

coherent, 110. 

confluent, 110. 

contagium of, 109. 

desiccation in, 112. 

diagnosis, 113. 

discrete, 110. 

eruption of, 111. 

hemorrhagic, 110, 113. 

invasion of, 111. 

malignant, 110, 113. 

prognosis, 114. 

stages of, 110. 



Variola, suppuration in, 112. 

symptomatology, 110. 

treatment, 114. 

vera, 110. 
Varioloid, 109. 

Vascular system, tuberculosis 
of, 283. 

Vaso-motor disturbances, 382. 
Veratrum viride, poisoning by, 

358. 
Vertigo, 416. 

cardiac, 417. 

epileptic, 417. 

essential, 418. 

gastric, 417. 

hysterical, 417. 

lithaemic, 418. 

organic, 417. 

peripheral, 417. 

special sense, 417. 

toxasmic, 418. 
Vision, contraction of field of, 

480. 

Voltolini's disease, 418. 
Vomiting, habitual, 850. 
nervous, 850. 

W. 

Walking typhoid fever, 130. 
Wandering spleen, 29. 
Wasting palsy, 570. 
Water-brash, 811, 828. 
Water-hammer pulse, 666. 
Weil's disease, 151. 
Werlhof s disease, 26. 
Westphal's symptom, 378, 579. 
Whip-worm, 340. 
Whooping-cough, 179. 
complications, 181. 
diagnosis, 181. 
treatment, 182. 
Wool-sorter's disease, 236. 
Woorari, poisoning by, 358. 
Worms, parasitic, 322. 

fluke, 335. 

Guinea- worm, 340. 

pin- worm, 338. 

round worm, 337. 

tape-worm, 323. 

thread-worm, 337. 

trichinae, 342. 

whip-worm, 340. 
Wrist-drop, 334. 
Writer's cramp, 455. 

X. 

Xanthopsia, 933. 

Xeroderma pigmentosum, 625. 

Y. 

Yellow fever, 226. 
course, 229. 
diagnosis, 229. 
morbid anatomy, 227. 
prognosis, 230. 
prophylaxis, 230. 
remission in, 228. 
symptomatology, 228. 
treatment, 230. 
zones of, 227. 



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